Provider Demographics
NPI:1912963513
Name:STARK, THOMAS E (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
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 1:644 NAPLES STREET
Mailing Address - Street 2:NAVAL BRANCH CLINIC CHULA VISTA
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911
Mailing Address - Country:US
Mailing Address - Phone:619-744-5393
Mailing Address - Fax:
Practice Address - Street 1:644 NAPLES ST
Practice Address - Street 2:CHULA VISTA NAVAL BRANCH CLINIC
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1636
Practice Address - Country:US
Practice Address - Phone:619-744-5355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44537-021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1040755OtherPHYSICIANS PLUS
WI43500700Medicaid
WI60052OtherDEAN HEALTH INSURANCE
WI1040755OtherPHYSICIANS PLUS
WI080186462Medicare PIN
WI60052OtherDEAN HEALTH INSURANCE
WI43500700Medicaid
WI1040755OtherPHYSICIANS PLUS