Provider Demographics
NPI:1902801301
Name:STARK, BRUCE M (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:M
Last Name:STARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S BUENA VISTA ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4569
Mailing Address - Country:US
Mailing Address - Phone:818-842-7145
Mailing Address - Fax:818-842-8202
Practice Address - Street 1:201 S BUENA VISTA ST
Practice Address - Street 2:SUITE 300
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4569
Practice Address - Country:US
Practice Address - Phone:818-842-7145
Practice Address - Fax:818-842-8202
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2023-10-13
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
CAG72204207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G722040Medicaid
CA00G722040Medicaid
CAF48009Medicare UPIN