Provider Demographics
NPI:1295916476
Name:KENNETH E STARK MD PA
Entity type:Organization
Organization Name:KENNETH E STARK MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-343-7735
Mailing Address - Street 1:1613 BANNING BEACH RD
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-2024
Mailing Address - Country:US
Mailing Address - Phone:352-343-7735
Mailing Address - Fax:352-343-7740
Practice Address - Street 1:1613 BANNING BEACH RD
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-2024
Practice Address - Country:US
Practice Address - Phone:352-343-7735
Practice Address - Fax:352-343-7740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0045588207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL09127OtherBCBS OF FLORIDA
FL370164600Medicaid
FL6515425OtherCIGNA
FLK7128Medicare PIN