Healthcare Provider Details

I. General information

NPI: 1750389169
Provider Name (Legal Business Name): ERIC WYGANT STARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2005
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 SOUTH ST
LAFAYETTE IN
47904-3027
US

IV. Provider business mailing address

PO BOX 5628
LAFAYETTE IN
47903-5628
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-4319
  • Fax: 765-448-2821
Mailing address:
  • Phone: 765-448-4319
  • Fax: 765-448-2921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number01030271A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: