Healthcare Provider Details

I. General information

NPI: 1710987664
Provider Name (Legal Business Name): RANDY W STARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 07/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 MAHALANI ST
WAILUKU HI
96793-2526
US

IV. Provider business mailing address

3916 STATE ST #300
SANTA BARBARA CA
93105-5602
US

V. Phone/Fax

Practice location:
  • Phone: 808-242-2343
  • Fax: 808-242-2465
Mailing address:
  • Phone: 805-563-3011
  • Fax: 805-564-5087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA73186
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: