Provider Demographics
NPI:1912981119
Name:STARK, STEPHEN H (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:H
Last Name:STARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 W HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-4716
Mailing Address - Country:US
Mailing Address - Phone:352-726-8353
Mailing Address - Fax:352-726-5038
Practice Address - Street 1:308 W HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4716
Practice Address - Country:US
Practice Address - Phone:352-726-8353
Practice Address - Fax:352-726-5038
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME30869207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2569084OtherCIGNA
FL269859500OtherMEDICAID GROUP
FLME30869OtherSTATE LICENSE NUMBER
FL10721764OtherCAQH
FL30064OtherBCBS
FL77940OtherMEDICARE GROUP ID
77940OtherBCBS GRP
FLCF1416OtherMEDICARE RR GROUP
FLP00144401OtherMEDICARE RR
FL056651900Medicaid
FL30064OtherBCBS
FLC61291Medicare UPIN