Provider Demographics
NPI:1710987664
Name:STARK, RANDY W (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:W
Last Name:STARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3916 STATE ST
Mailing Address - Street 2:#300
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105-5602
Mailing Address - Country:US
Mailing Address - Phone:805-563-3011
Mailing Address - Fax:805-564-5087
Practice Address - Street 1:221 MAHALANI ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2526
Practice Address - Country:US
Practice Address - Phone:808-242-2343
Practice Address - Fax:808-242-2465
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA73186207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A731860Medicaid
CA00A731860Medicare ID - Type Unspecified
HIBP604ZMedicare PIN
CAH61246Medicare UPIN