Provider Demographics
NPI:1124575915
Name:STARK, ELISABETH L
Entity type:Individual
Prefix:MS
First Name:ELISABETH
Middle Name:L
Last Name:STARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 N SAINT CLAIR ST STE 14-200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5966
Mailing Address - Country:US
Mailing Address - Phone:312-695-7382
Mailing Address - Fax:312-695-0014
Practice Address - Street 1:675 N SAINT CLAIR ST STE 14-200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5966
Practice Address - Country:US
Practice Address - Phone:312-695-7382
Practice Address - Fax:312-695-0014
Is Sole Proprietor?:No
Enumeration Date:2016-09-08
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036170933207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program