Provider Demographics
NPI:1952539348
Name:VIRGINIA STARK-VANCE, M.D., P.A.
Entity Type:Organization
Organization Name:VIRGINIA STARK-VANCE, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:STARK-VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-926-2555
Mailing Address - Street 1:1325 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2158
Mailing Address - Country:US
Mailing Address - Phone:817-926-2555
Mailing Address - Fax:817-926-2519
Practice Address - Street 1:1325 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2158
Practice Address - Country:US
Practice Address - Phone:817-926-2555
Practice Address - Fax:817-926-2519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-24
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9819207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX900003253OtherRR MEDICARE
TX900003253OtherRR MEDICARE