MEDICARE: DR. ROHN TAYLOR STARK JR. PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	26386	CA
2	103TC0700X	Clinical Psychologist	PSY26386	CA

General Provider Information

NPI Number	:	1902219850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROHN TAYLOR STARK JR. PSY.D.

Provider Business Mailing Address
First Line	:	PO BOX 18631
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95158-8631
Country	:	US
Telephone Number	:	808-283-0716
Fax Number	:

Provider Business Practice Location Address
First Line	:	4929 WILSHIRE BLVD STE 510
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-3820
Country	:	US
Telephone Number	:	562-904-3999
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2014
Last Update Date	:	06/24/2021

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