Provider Demographics
NPI:1063428746
Name:STARK, CAROL K (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:K
Last Name:STARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:KINYON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2025 SLOAN PL
Mailing Address - Street 2:STE 35
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2007
Mailing Address - Country:US
Mailing Address - Phone:651-772-1572
Mailing Address - Fax:651-772-1889
Practice Address - Street 1:4786 BANNING AVE
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3264
Practice Address - Country:US
Practice Address - Phone:651-426-6402
Practice Address - Fax:651-429-3402
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31736207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN190592900Medicaid
MN190592900Medicaid