Healthcare Provider Details

I. General information

NPI: 1497794523
Provider Name (Legal Business Name): ROBERT TIMOTHY STARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SWEET BAY CT
MOULTRIE GA
31768-6784
US

IV. Provider business mailing address

PO BOX 2876
MOULTRIE GA
31776-2876
US

V. Phone/Fax

Practice location:
  • Phone: 229-985-2198
  • Fax:
Mailing address:
  • Phone: 229-985-2198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number45632
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: