MEDICARE: CAROL K STARK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	31736	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063428746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROL K STARK MD

Provider Business Mailing Address
First Line	:	2025 SLOAN PL
Second Line	:	STE 35
City	:	SAINT PAUL
State	:	MN
Zip	:	55117-2007
Country	:	US
Telephone Number	:	651-772-1572
Fax Number	:	651-772-1889

Provider Business Practice Location Address
First Line	:	4786 BANNING AVE
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3264
Country	:	US
Telephone Number	:	651-426-6402
Fax Number	:	651-429-3402

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	10/14/2011

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