=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760432272
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VIVIAN RUTH BARBARA-STARK MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2006
-----------------------------------------------------
Last Update Date | 07/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 JOHNSON FERRY RD STE 1102
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342-1605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-250-2007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3530 HABERSHAM ROAD NW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-249-4034
-----------------------------------------------------
Fax | 404-841-0068
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 028347
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------