Provider Demographics
NPI:1316973506
Name:STARK, GARRY H (MD)
Entity type:Individual
Prefix:
First Name:GARRY
Middle Name:H
Last Name:STARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 LAKEVILLE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1661
Mailing Address - Country:US
Mailing Address - Phone:516-328-9797
Mailing Address - Fax:516-352-6579
Practice Address - Street 1:2035 LAKEVILLE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1661
Practice Address - Country:US
Practice Address - Phone:516-328-9797
Practice Address - Fax:516-352-6579
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY158466207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01722870Medicaid
NY9255APMedicare ID - Type Unspecified
NY01722870Medicaid