Provider Demographics
NPI:1407594682
Name:STARK, BRETT EVAN (DO)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:EVAN
Last Name:STARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NAVAL HEALTH CLINIC PATUXENT RIVER
Mailing Address - Street 2:47149 BUSE RD BLDG 1370
Mailing Address - City:PATUXENT RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:20670
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HEALTH CLINIC PATUXENT RIVER
Practice Address - Street 2:47149 BUSE RD BLDG 1370
Practice Address - City:PATUXENT RIVER
Practice Address - State:MD
Practice Address - Zip Code:20670
Practice Address - Country:US
Practice Address - Phone:757-953-5008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102208242208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program