Healthcare Provider Details

I. General information

NPI: 1174564330
Provider Name (Legal Business Name): CLIFFORD STARK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 W 24TH ST FL 2
NEW YORK NY
10010-3560
US

IV. Provider business mailing address

30 W 24TH ST FL 2
NEW YORK NY
10010-3560
US

V. Phone/Fax

Practice location:
  • Phone: 212-366-5100
  • Fax: 212-366-6275
Mailing address:
  • Phone: 212-366-5100
  • Fax: 212-366-6275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number224735
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: