Provider Demographics
NPI:1588226989
Name:STARK, ALEXANDER JONATHON (MS)
Entity Type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:JONATHON
Last Name:STARK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14719 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7203
Mailing Address - Country:US
Mailing Address - Phone:623-832-9355
Mailing Address - Fax:
Practice Address - Street 1:14719 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7203
Practice Address - Country:US
Practice Address - Phone:623-832-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ262957251OtherSENIOR HMOS
AZ262957251Medicaid