Basic Information
| Provider Information | |||||||||
| NPI: | 1295970143 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RANDY W STARK MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3916 STATE ST | ||||||||
| Address2: | #300 | ||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931055602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055633011 | ||||||||
| FaxNumber: | 8055645087 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 MAHALANI ST | ||||||||
| Address2: | |||||||||
| City: | WAILUKU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967932526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084635100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2008 | ||||||||
| LastUpdateDate: | 06/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | STARK | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8055633011 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | HI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 630287 | 05 | HI | MEDICAID |