Healthcare Provider Details

I. General information

NPI: 1093087579
Provider Name (Legal Business Name): JUSTIN MYLES STARK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2012
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 PARK AVE STE 200
ORANGE PARK FL
32073-5574
US

IV. Provider business mailing address

2300 PARK AVE STE 200
ORANGE PARK FL
32073-5574
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-2900
  • Fax: 904-269-1140
Mailing address:
  • Phone: 904-269-2900
  • Fax: 904-269-1140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS19751
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number075156
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS19751
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: