Provider Demographics
NPI:1922087618
Name:STARK, JOHN B (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:STARK
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 1:316 VIEW POINT PL
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6151
Mailing Address - Country:US
Mailing Address - Phone:904-825-0540
Mailing Address - Fax:904-209-1055
Practice Address - Street 1:ONE ORTHOPAEDIC PLACE
Practice Address - Street 2:
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4202
Practice Address - Country:US
Practice Address - Phone:904-825-0540
Practice Address - Fax:904-209-1055
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96534207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036112556Medicaid
FL1174540001OtherDMERC CIGNA GOUT SVCS
FL1174540001OtherDMERC
ILF74196Medicare UPIN