Provider Demographics
NPI:1760661938
Name:STARKE FAMILY MEDICINE CLINIC 01 INC
Entity Type:Organization
Organization Name:STARKE FAMILY MEDICINE CLINIC 01 INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NATALIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHIRIAEVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-964-1888
Mailing Address - Street 1:1546 S WATER ST
Mailing Address - Street 2:
Mailing Address - City:STARKE
Mailing Address - State:FL
Mailing Address - Zip Code:32091-4511
Mailing Address - Country:US
Mailing Address - Phone:904-964-1888
Mailing Address - Fax:904-964-1884
Practice Address - Street 1:1546 S WATER ST
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-4511
Practice Address - Country:US
Practice Address - Phone:904-964-1888
Practice Address - Fax:904-964-1884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0081878207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE2513ZMedicare PIN