Provider Demographics
NPI:1124112255
Name:STARK, JEFFREY HOWARD (DPM)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:HOWARD
Last Name:STARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6216 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-6236
Mailing Address - Country:US
Mailing Address - Phone:718-821-2161
Mailing Address - Fax:718-821-1252
Practice Address - Street 1:6216 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-6236
Practice Address - Country:US
Practice Address - Phone:718-821-2161
Practice Address - Fax:718-821-1252
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004970213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01758718Medicaid
NYP55121Medicare PIN
NYU32483Medicare UPIN
NY01758718Medicaid