Healthcare Provider Details

I. General information

NPI: 1922087618
Provider Name (Legal Business Name): JOHN B STARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE ORTHOPAEDIC PLACE
ST. AUGUSTINE FL
32086-4202
US

IV. Provider business mailing address

316 VIEW POINT PL
ST AUGUSTINE FL
32080-6151
US

V. Phone/Fax

Practice location:
  • Phone: 904-825-0540
  • Fax: 904-209-1055
Mailing address:
  • Phone: 904-825-0540
  • Fax: 904-209-1055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME96534
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberME96534
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: