Healthcare Provider Details

I. General information

NPI: 1306816996
Provider Name (Legal Business Name): JOHN GREGORY STARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NICOLLET MALL SUITE 715
MINNEAPOLIS MN
55402-2595
US

IV. Provider business mailing address

825 NICOLLET MALL SUITE 715
MINNEAPOLIS MN
55402-2606
US

V. Phone/Fax

Practice location:
  • Phone: 612-332-2324
  • Fax: 612-332-1019
Mailing address:
  • Phone: 612-332-2324
  • Fax: 612-332-1019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number23369
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: