Provider Demographics
NPI:1801844105
Name:CUSHENBERRY STARKS, PAMELA ANN (MD)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:ANN
Last Name:CUSHENBERRY STARKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:A
Other - Last Name:STARKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-521-6097
Mailing Address - Fax:
Practice Address - Street 1:3612 DALE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-0500
Practice Address - Country:US
Practice Address - Phone:209-522-0146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62497207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A624970Medicaid
CAH04881Medicare UPIN
CA00A624970Medicare ID - Type UnspecifiedMEDICARE NUMBER
CA00A624971Medicare PIN