Provider Demographics
NPI:1336816917
Name:STARK, JILL (DPM)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 PENSION RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BOOTHBAY
Mailing Address - State:ME
Mailing Address - Zip Code:04537-4810
Mailing Address - Country:US
Mailing Address - Phone:201-294-5672
Mailing Address - Fax:
Practice Address - Street 1:104 PENSION RIDGE RD
Practice Address - Street 2:
Practice Address - City:BOOTHBAY
Practice Address - State:ME
Practice Address - Zip Code:04537-4810
Practice Address - Country:US
Practice Address - Phone:201-294-5672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006857213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist