Provider Demographics
NPI:1881643153
Name:STORK, JOHN J (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:STORK
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 1:6716 NW 11TH PL
Mailing Address - Street 2:STE 200
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4215
Mailing Address - Country:US
Mailing Address - Phone:352-331-9729
Mailing Address - Fax:352-331-0136
Practice Address - Street 1:6716 NW 11TH PL
Practice Address - Street 2:STE 200
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4215
Practice Address - Country:US
Practice Address - Phone:352-331-9729
Practice Address - Fax:352-331-0136
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME480782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL239216OtherAVMED
FL052302000Medicaid
FL10431OtherBCBSFL
FLP00323916OtherRAIL ROAD MEDICARE
FL270855OtherAVMED
FLP000316736OtherRAIL ROAD MEDICARE
FLP000316736OtherRAIL ROAD MEDICARE
FL10431XMedicare PIN
FL052302000Medicaid
FL052302000Medicaid