Healthcare Provider Details

I. General information

NPI: 1487949384
Provider Name (Legal Business Name): TRAVIS JACK STARK D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9010 LORTON STATION BLVD STE 270
LORTON VA
22079-4798
US

IV. Provider business mailing address

PO BOX 669
YUMA AZ
85366-2329
US

V. Phone/Fax

Practice location:
  • Phone: 540-898-6500
  • Fax: 540-834-0363
Mailing address:
  • Phone: 928-247-6516
  • Fax: 928-366-1075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103301505
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: