Healthcare Provider Details

I. General information

NPI: 1659295772
Provider Name (Legal Business Name): COLEMAN R STARK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

794 BLANDING BLVD
ORANGE PARK FL
32065-5721
US

IV. Provider business mailing address

1370 LAKEWOOD LN
FLEMING ISLAND FL
32003-9013
US

V. Phone/Fax

Practice location:
  • Phone: 904-203-1888
  • Fax: 904-203-1888
Mailing address:
  • Phone: 904-203-1888
  • Fax: 904-203-1888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number44932
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: