Provider Demographics
NPI:1750460341
Name:STARK, T GAIL (DPM)
Entity Type:Individual
Prefix:DR
First Name:T
Middle Name:GAIL
Last Name:STARK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:TERESSA
Other - Middle Name:GAIL
Other - Last Name:STARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:PO BOX 34150
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-4150
Mailing Address - Country:US
Mailing Address - Phone:850-982-2625
Mailing Address - Fax:
Practice Address - Street 1:11739 CHANTICLEER DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507-4150
Practice Address - Country:US
Practice Address - Phone:850-982-2625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2420213E00000X, 213EP1101X, 213ER0200X, 213ES0000X, 213ES0131X
AL160213E00000X, 213EP1101X, 213ER0200X, 213ES0000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390273100Medicaid
FL4674610001Medicare NSC
FLU39544Medicare UPIN
FL65342Medicare PIN