Provider Demographics
NPI:1134198252
Name:STARK, ERIC R (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:R
Last Name:STARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1462
Mailing Address - Fax:360-729-3104
Practice Address - Street 1:FAMILY MEDICINE
Practice Address - Street 2:835 EAST FAIRHAVEN AVENUE
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233-0329
Practice Address - Country:US
Practice Address - Phone:360-856-7960
Practice Address - Fax:360-755-1405
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2019-07-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00033859207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8206153Medicaid
WA8206153Medicaid
WA8206153Medicaid