Healthcare Provider Details

I. General information

NPI: 1376505404
Provider Name (Legal Business Name): HENRY KAY STARK D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 10/14/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 PARK AVE
LAKE PARK FL
33403-2503
US

IV. Provider business mailing address

701 PARK AVE
LAKE PARK FL
33403-2503
US

V. Phone/Fax

Practice location:
  • Phone: 561-284-6886
  • Fax: 561-627-2199
Mailing address:
  • Phone: 561-284-6886
  • Fax: 561-627-2199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1272
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: