Provider Demographics
NPI:1760422315
Name:STARK, THOMAS F (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:F
Last Name:STARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3726 BROADWAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3787
Mailing Address - Country:US
Mailing Address - Phone:425-317-9119
Mailing Address - Fax:
Practice Address - Street 1:3726 BROADWAY
Practice Address - Street 2:SUITE 201
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3787
Practice Address - Country:US
Practice Address - Phone:425-317-9119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2008-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042555207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8360216Medicaid
WAP00048799OtherRAILROAD MEDICARE
WA0172186OtherLABOR AND INDUSTRY
WAMD00042555OtherSTATE LICENSE NUMBER
WAP00048799OtherRAILROAD MEDICARE
WAAB38488Medicare PIN