Provider Demographics
NPI:1215145032
Name:STARK, TIMOTHY DANIEL (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DANIEL
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 1:228 DAY ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94131-2417
Mailing Address - Country:US
Mailing Address - Phone:415-269-8509
Mailing Address - Fax:
Practice Address - Street 1:250 BON AIR RD
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904
Practice Address - Country:US
Practice Address - Phone:415-925-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 99196207L00000X
CAA97662207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABA073AMedicare PIN
CABA073YMedicare PIN