Provider Demographics
NPI:1306816996
Name:STARK, JOHN GREGORY (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GREGORY
Last Name:STARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:825 NICOLLET MALL
Mailing Address - Street 2:SUITE 715
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-2606
Mailing Address - Country:US
Mailing Address - Phone:612-332-2324
Mailing Address - Fax:612-332-1019
Practice Address - Street 1:825 NICOLLET MALL
Practice Address - Street 2:SUITE 715
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2595
Practice Address - Country:US
Practice Address - Phone:612-332-2324
Practice Address - Fax:612-332-1019
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN23369204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN126002200Medicaid
MN09-01240OtherPHP/MEDICA
MN23369OtherMINNESOTA MEDICAL LICENSE
MN23369OtherMINNESOTA MEDICAL LICENSE
MN23369OtherMINNESOTA MEDICAL LICENSE