Provider Demographics
NPI:1013936764
Name:STARK, CHRISTOPHER JON
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JON
Last Name:STARK
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:CHRISTOPER
Other - Middle Name:J
Other - Last Name:STARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 560825
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80256-0825
Mailing Address - Country:US
Mailing Address - Phone:719-595-7580
Mailing Address - Fax:719-545-0176
Practice Address - Street 1:400 W 16TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2745
Practice Address - Country:US
Practice Address - Phone:719-595-2218
Practice Address - Fax:719-595-7994
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39876207R00000X
MN50157207RC0200X
CODR.0058428208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64125065Medicaid
CO9000147685Medicaid
MN810000174Medicare PIN
KY64125065Medicaid