Provider Demographics
NPI:1174564330
Name:STARK, CLIFFORD (DO)
Entity type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:
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 1:30 W 24TH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-3560
Mailing Address - Country:US
Mailing Address - Phone:212-366-5100
Mailing Address - Fax:212-366-6275
Practice Address - Street 1:30 W 24TH ST FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-3560
Practice Address - Country:US
Practice Address - Phone:212-366-5100
Practice Address - Fax:212-366-6275
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224735207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH48841Medicare UPIN
NY5178B1Medicare ID - Type Unspecified