Provider Demographics
NPI:1992783583
Name:STARK, GLENN M (DC)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:M
Last Name:STARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 COMMONWEALTH BLVD E
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-2014
Mailing Address - Country:US
Mailing Address - Phone:276-632-2226
Mailing Address - Fax:276-632-2395
Practice Address - Street 1:425 COMMONWEALTH BLVD E
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-2014
Practice Address - Country:US
Practice Address - Phone:276-632-2226
Practice Address - Fax:276-632-2395
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000930111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU51618Medicare UPIN
VA00W211M01Medicare ID - Type Unspecified