MEDICARE: KENNETH E STARK M.D.

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	207RR0500X	Rheumatology Physician	045588	FL

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	:	1558346262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH E STARK M.D.

Provider Business Mailing Address
First Line	:	1613 BANNING BEACH RD
Second Line	:
City	:	TAVARES
State	:	FL
Zip	:	32778-2024
Country	:	US
Telephone Number	:	352-343-7735
Fax Number	:	352-343-7740

Provider Business Practice Location Address
First Line	:	1613 BANNING BEACH RD
Second Line	:
City	:	TAVARES
State	:	FL
Zip	:	32778-2024
Country	:	US
Telephone Number	:	352-343-7735
Fax Number	:	352-343-7740

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

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	10/09/2012

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Directions to “ KENNETH E STARK M.D.” Practice Location

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