MEDICARE: T GAIL STARK DPM PA

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	213E00000X	Podiatrist	PO2420	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1400157	OTHER	FL	GHI
2	5439096	OTHER	FL	AETNA
3	59138421	OTHER	AL	BLUE CROSS ALABAMA

General Provider Information

NPI Number	:	1568541142
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	T GAIL STARK DPM PA

Provider Business Mailing Address
First Line	:	12385 SORRENTO RD
Second Line	:	SUITE D-4
City	:	PENSACOLA
State	:	FL
Zip	:	32507-8664
Country	:	US
Telephone Number	:	850-497-8876
Fax Number	:	850-497-1721

Provider Business Practice Location Address
First Line	:	12385 SORRENTO RD
Second Line	:	SUITE D-4
City	:	PENSACOLA
State	:	FL
Zip	:	32507-8664
Country	:	US
Telephone Number	:	850-497-8876
Fax Number	:	850-497-1721

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. T GAIL STARK
Credential	:	DPM
Telephone Number	:	850-497-8876

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	08/22/2020

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Directions to “T GAIL STARK DPM PA ” Practice Location

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