Provider Demographics
NPI:1366415358
Name:STARK, RAYMOND
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:
Last Name:STARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 RIVERSIDE DR
Mailing Address - Street 2:#14B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-1859
Mailing Address - Country:US
Mailing Address - Phone:212-864-4428
Mailing Address - Fax:
Practice Address - Street 1:3959 BROADWAY
Practice Address - Street 2:COLUMBIA UNIVERSITY DEPARTMENT PEDIATRICS
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-927-3214
Practice Address - Fax:212-544-1974
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1169552080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5998301OtherNEW JERSEY MEDICAID
NY00708452Medicaid