Provider Demographics
NPI:1861024622
Name:STARK, TIMOTHY WAYNE
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:STARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12508 JONES MALTSBERGER RD STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-4215
Mailing Address - Country:US
Mailing Address - Phone:210-590-4000
Mailing Address - Fax:210-590-4585
Practice Address - Street 1:4532 W GATE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1463
Practice Address - Country:US
Practice Address - Phone:512-892-7337
Practice Address - Fax:512-892-7339
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist