=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487949384
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRAVIS JACK STARK D.P.M.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2011
-----------------------------------------------------
Last Update Date | 06/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2503 S AVENUE A STE 2
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364-7174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-783-0092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 669
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85366-2329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-247-6516
-----------------------------------------------------
Fax | 928-366-1075
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 311
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 5315051097
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 000983
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------