Provider Demographics
NPI:1689674921
Name:STARK, BRUCE I (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:I
Last Name:STARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:915 OLD FERN HILL RD
Mailing Address - Street 2:BUILDING B SUITE 200
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-4269
Mailing Address - Country:US
Mailing Address - Phone:610-696-1230
Mailing Address - Fax:610-918-0803
Practice Address - Street 1:915 OLD FERN HILL RD
Practice Address - Street 2:BUILDING B SUITE 200
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-4269
Practice Address - Country:US
Practice Address - Phone:610-696-1230
Practice Address - Fax:610-918-0803
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD022743E207WX0200X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012038590007Medicaid
PA001203859Medicaid
PA0012038590007Medicaid
PA001203859Medicaid
PA405379H6RMedicare PIN