Provider Demographics
NPI:1679579577
Name:STARK, MICHAEL LEE (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:STARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4445 LAKE FOREST DR STE 600
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-3744
Mailing Address - Country:US
Mailing Address - Phone:513-569-3741
Mailing Address - Fax:937-492-1132
Practice Address - Street 1:1118 FAIRINGTON DR
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-8913
Practice Address - Country:US
Practice Address - Phone:937-492-3755
Practice Address - Fax:937-492-1132
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH3380207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0533462Medicaid
OHA16229Medicare UPIN
OH0533462Medicaid