Provider Demographics
NPI:1093727166
Name:STARK, EDWARD (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
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 1:355 W 52ND ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-6239
Mailing Address - Country:US
Mailing Address - Phone:646-754-2100
Mailing Address - Fax:646-754-2148
Practice Address - Street 1:355 W 52ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-6239
Practice Address - Country:US
Practice Address - Phone:646-754-2100
Practice Address - Fax:646-754-2148
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041680208800000X
NY179696208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA340015407OtherRAILROAD MEDICARE
GA000707891GMedicaid
GA000707891GMedicaid
GA000707891GMedicaid
GA34BDFFCTMedicare PIN