Provider Demographics
NPI:1932140027
Name:STARK, STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
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 1:88 COVERED BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-5218
Mailing Address - Country:US
Mailing Address - Phone:916-425-0404
Mailing Address - Fax:916-678-6762
Practice Address - Street 1:500 UNIVERSITY AVE STE 104
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-6504
Practice Address - Country:US
Practice Address - Phone:916-425-0404
Practice Address - Fax:916-678-6762
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60200174400000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G602000Medicaid
CAA53563OtherUPIN
CA00G602000Medicaid
CAA53563OtherUPIN