Provider Demographics
NPI:1710927769
Name:STARK, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:STARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9746
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5040
Mailing Address - Country:US
Mailing Address - Phone:207-791-3888
Mailing Address - Fax:207-828-7850
Practice Address - Street 1:161 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-6825
Practice Address - Country:US
Practice Address - Phone:603-431-5154
Practice Address - Fax:603-430-5033
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NH9824207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE435003Medicare PIN