Provider Demographics
NPI:1548309651
Name:STARK, NEIL BRANDAN (DO)
Entity type:Individual
Prefix:
First Name:NEIL
Middle Name:BRANDAN
Last Name:STARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 BARKLEY BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-6614
Mailing Address - Country:US
Mailing Address - Phone:360-671-3345
Mailing Address - Fax:530-899-0142
Practice Address - Street 1:1302 LOWE AVE
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98229-2522
Practice Address - Country:US
Practice Address - Phone:360-410-2299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2OA6829207Q00000X
WAOP61153857207QA0401X
CA20A6829207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG47503Medicare UPIN