Provider Demographics
NPI:1902018641
Name:STARK, JULIE MARIA (MD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:MARIA
Last Name:STARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:MARIA
Other - Last Name:DONNELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:436 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-3210
Practice Address - Country:US
Practice Address - Phone:260-209-7111
Practice Address - Fax:260-222-2835
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121864207Q00000X
IN01073161A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201190690Medicaid
IL1528046323OtherFACILITY NPI #1528046323