Provider Demographics
NPI:1639354244
Name:RANDOLPH W. STARK, M.D., PA
Entity Type:Organization
Organization Name:RANDOLPH W. STARK, M.D., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HEINRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-257-9619
Mailing Address - Street 1:10680 CRESTWOOD DR STE B
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-4402
Mailing Address - Country:US
Mailing Address - Phone:703-361-6054
Mailing Address - Fax:703-330-9095
Practice Address - Street 1:10680 CRESTWOOD DR STE B
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-4402
Practice Address - Country:US
Practice Address - Phone:703-361-6054
Practice Address - Fax:703-330-9095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036334174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAGC1182Medicare PIN
VAB06147Medicare UPIN