Provider Demographics
NPI:1194891424
Name:JEFFREY M STARK, DPM
Entity type:Organization
Organization Name:JEFFREY M STARK, DPM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:516-764-3500
Mailing Address - Street 1:1 DUNCAN PL
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-1306
Mailing Address - Country:US
Mailing Address - Phone:516-765-3500
Mailing Address - Fax:516-536-4236
Practice Address - Street 1:1 DUNCAN PL
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-1306
Practice Address - Country:US
Practice Address - Phone:516-765-3500
Practice Address - Fax:516-536-4236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003165-1213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00490042Medicaid
NY00490042Medicaid
NY3933130001Medicare NSC
NY480000074Medicare Oscar/Certification