Provider Demographics
NPI:1154555795
Name:D STARKS MD INCORPORATED
Entity type:Organization
Organization Name:D STARKS MD INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:D'MITRI
Authorized Official - Middle Name:
Authorized Official - Last Name:STARKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-625-0661
Mailing Address - Street 1:5153 HOLT BLVD
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-4837
Mailing Address - Country:US
Mailing Address - Phone:909-625-0661
Mailing Address - Fax:909-625-7761
Practice Address - Street 1:5153 HOLT BLVD
Practice Address - Street 2:SUITE B-2
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-4837
Practice Address - Country:US
Practice Address - Phone:909-625-0661
Practice Address - Fax:909-625-7761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49823261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G498230Medicaid
CA00G498230Medicaid
CAA51477Medicare PIN