=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114131265
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STARKS PEDIATRICS AT MALLARD CREEK, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2007
-----------------------------------------------------
Last Update Date | 02/25/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2315 W. ARBORS DRIVE SUITE 115
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28262-2639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-717-2826
-----------------------------------------------------
Fax | 704-971-5014
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2315 W. ARBORS DRIVE SUITE 115
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28262-2639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-717-2826
-----------------------------------------------------
Fax | 704-971-5014
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LAWANNA MARIE STARKS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 704-717-2826
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 2006-00525
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------