Healthcare Provider Details

I. General information

NPI: 1750460341
Provider Name (Legal Business Name): T GAIL STARK DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TERESSA GAIL STARK DPM

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11739 CHANTICLEER DR
PENSACOLA FL
32507-4150
US

IV. Provider business mailing address

PO BOX 34150
PENSACOLA FL
32507-4150
US

V. Phone/Fax

Practice location:
  • Phone: 850-982-2625
  • Fax:
Mailing address:
  • Phone: 850-982-2625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO2420
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number160
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPO2420
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number160
License Number StateAL
# 5
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License NumberPO2420
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number160
License Number StateAL
# 7
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberPO2420
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number160
License Number StateAL
# 9
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO2420
License Number StateFL
# 10
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number160
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: