Provider Demographics
NPI:1487949384
Name:STARK, TRAVIS JACK (DPM)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:JACK
Last Name:STARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-2329
Mailing Address - Country:US
Mailing Address - Phone:928-247-6516
Mailing Address - Fax:928-366-1075
Practice Address - Street 1:2503 S AVENUE A STE 2
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7174
Practice Address - Country:US
Practice Address - Phone:928-783-0092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK311213ES0103X
MI5315051097213ES0103X
AZ000983213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK418589ZPRXMedicare PIN