Healthcare Provider Details

I. General information

NPI: 1457379612
Provider Name (Legal Business Name): JAMES E STARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10150 SE 32ND AVE
MILWAUKIE OR
97222-6516
US

IV. Provider business mailing address

PO BOX 547
CORVALLIS OR
97339-0547
US

V. Phone/Fax

Practice location:
  • Phone: 503-513-8300
  • Fax:
Mailing address:
  • Phone: 541-758-5047
  • Fax: 541-758-3713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number24884
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: