Provider Demographics
NPI:1649714734
Name:STARKS MEDICAL GROUP A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:STARKS MEDICAL GROUP A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-625-0661
Mailing Address - Street 1:5153 HOLT BLVD
Mailing Address - Street 2:SUITE B2
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-4837
Mailing Address - Country:US
Mailing Address - Phone:909-625-0661
Mailing Address - Fax:909-625-7761
Practice Address - Street 1:5153 HOLT BLVD
Practice Address - Street 2:SUITE B2
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-4837
Practice Address - Country:US
Practice Address - Phone:909-625-0661
Practice Address - Fax:909-625-7761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207V00000X, 208D00000X
CAA761212085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty