Healthcare Provider Details

I. General information

NPI: 1982950267
Provider Name (Legal Business Name): PATRICK STARK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7840 NATURAL BRIDGE BLVD PATIENT CARE CENTER
SAINT LOUIS MO
63121-4617
US

IV. Provider business mailing address

1 UNIVERSITY BLVD PATIENT CARE CENTER
SAINT LOUIS MO
63121-4400
US

V. Phone/Fax

Practice location:
  • Phone: 314-516-5131
  • Fax:
Mailing address:
  • Phone: 314-516-5131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2753
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2015014189
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: