Healthcare Provider Details

I. General information

NPI: 1861197303
Provider Name (Legal Business Name): PHILIP KONRAD STARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 VALLEY RD
LINCOLN NE
68510-4855
US

IV. Provider business mailing address

4600 VALLEY RD
LINCOLN NE
68510-4855
US

V. Phone/Fax

Practice location:
  • Phone: 402-483-4591
  • Fax: 402-483-5633
Mailing address:
  • Phone: 402-483-4591
  • Fax: 402-483-5633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36579
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: