Provider Demographics
NPI:1598862526
Name:STARK, DALE M (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:M
Last Name:STARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:9281 OFFICE PARK CIR
Practice Address - Street 2:#120
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-8068
Practice Address - Country:US
Practice Address - Phone:916-691-5999
Practice Address - Fax:916-691-6717
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA41495208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A414950Medicaid
00A414950Medicare ID - Type Unspecified
F25325Medicare UPIN