Provider Demographics
NPI:1902018641
Name:STARK, JULIE (MD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:STARK
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1306 E 7TH ST STE A
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-2537
Practice Address - Country:US
Practice Address - Phone:260-925-1255
Practice Address - Fax:260-925-1256
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073161A207Q00000X
IL036121864207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201190690Medicaid
IL1528046323OtherFACILITY NPI #1528046323