Provider Demographics
NPI:1780655928
Name:STARK, RON H (MD)
Entity Type:Individual
Prefix:
First Name:RON
Middle Name:H
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 1:3077 N MAYFAIR RD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4305
Mailing Address - Country:US
Mailing Address - Phone:414-258-2323
Mailing Address - Fax:414-258-2736
Practice Address - Street 1:3077 N MAYFAIR RD
Practice Address - Street 2:SUITE 306
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-4305
Practice Address - Country:US
Practice Address - Phone:414-258-2323
Practice Address - Fax:414-258-2736
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI225452086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI22545OtherMEDICAL LICENSE
WI30741000Medicaid
AS8894405OtherDEA
B56831Medicare UPIN