Provider Demographics
NPI:1861443483
Name:STARK-VANCE, VIRGINIA I (MD)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:I
Last Name:STARK-VANCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 FOREST LN.
Mailing Address - Street 2:STE. C-648
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230
Mailing Address - Country:US
Mailing Address - Phone:972-566-2622
Mailing Address - Fax:972-566-2625
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:C-648
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230
Practice Address - Country:US
Practice Address - Phone:972-566-2622
Practice Address - Fax:972-566-2625
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9819174400000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXOA5172Medicare PIN
TXG16778Medicare UPIN