MEDICARE: DR. JEFFREY M STARK D.P.M.

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	213EP1101X	Primary Podiatric Medicine Podiatrist	NOO3165-1	NY
2	213ES0103X	Foot & Ankle Surgery Podiatrist	N003165-1	NY

General Provider Information

NPI Number	:	1114922994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY M STARK D.P.M.

Provider Business Mailing Address
First Line	:	1 DUNCAN PL
Second Line	:
City	:	OCEANSIDE
State	:	NY
Zip	:	11572-1306
Country	:	US
Telephone Number	:	516-764-3500
Fax Number	:	516-536-4236

Provider Business Practice Location Address
First Line	:	1 DUNCAN PL
Second Line	:
City	:	OCEANSIDE
State	:	NY
Zip	:	11572-1306
Country	:	US
Telephone Number	:	516-764-3500
Fax Number	:	516-536-4236

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

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	05/06/2010

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