Healthcare Provider Details

I. General information

NPI: 1902801301
Provider Name (Legal Business Name): BRUCE M STARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date: 03/21/2006
Reactivation Date: 04/05/2006

III. Provider practice location address

201 S BUENA VISTA ST SUITE 300
BURBANK CA
91505-4569
US

IV. Provider business mailing address

201 S BUENA VISTA ST SUITE 300
BURBANK CA
91505-4569
US

V. Phone/Fax

Practice location:
  • Phone: 818-842-7145
  • Fax: 818-842-8202
Mailing address:
  • Phone: 818-842-7145
  • Fax: 818-842-8202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG72204
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberG72204
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: