Provider Demographics
NPI:1841203957
Name:STARK, BRETT S (DPM)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:S
Last Name:STARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N DEAN RD
Mailing Address - Street 2:SUITE 5 PMB 180
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-4404
Mailing Address - Country:US
Mailing Address - Phone:334-466-1401
Mailing Address - Fax:334-466-1433
Practice Address - Street 1:890 N DEAN RD STE 400
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36830-9440
Practice Address - Country:US
Practice Address - Phone:334-466-1401
Practice Address - Fax:334-641-0075
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL225213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051503568OtherBLUE CROSS BLUE SHIELD
480033606OtherRR MCR
051529739OtherBLUE CROSS BLUE SHIELD
051530652OtherBLUE CROSS BLUE SHIELD
51503568Medicare PIN
051529739OtherBLUE CROSS BLUE SHIELD
AL4318200001Medicare NSC