Provider Demographics
NPI:1538219332
Name:STARK, MAUREEN ANN (MD)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:ANN
Last Name:STARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 A COMMERCE PARK DR
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-8349
Mailing Address - Country:US
Mailing Address - Phone:614-523-3918
Mailing Address - Fax:614-523-3900
Practice Address - Street 1:115 A COMMERCE PARK DR
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-8349
Practice Address - Country:US
Practice Address - Phone:614-523-3918
Practice Address - Fax:614-523-3900
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0363872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
E76387Medicare UPIN
ST0659012Medicare ID - Type Unspecified