Provider Demographics
NPI:1598708950
Name:STARK, JAMES C (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:C
Last Name:STARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2123 W 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4136
Mailing Address - Country:US
Mailing Address - Phone:405-372-3724
Mailing Address - Fax:405-743-1042
Practice Address - Street 1:2123 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4136
Practice Address - Country:US
Practice Address - Phone:405-372-3724
Practice Address - Fax:405-743-1042
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK949152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0210790001OtherPALMETTO GOVERNMENT BENEFITS ADMINISTRATORS
OK410019936OtherRAILROAD MEDICARE
OK100766010AMedicaid
OK0210790001Medicare NSC
OK0210790001OtherPALMETTO GOVERNMENT BENEFITS ADMINISTRATORS