Basic Information
Provider Information | |||||||||
NPI: | 1750389169 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STARK | ||||||||
FirstName: | ERIC | ||||||||
MiddleName: | WYGANT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5628 | ||||||||
Address2: |   | ||||||||
City: | LAFAYETTE | ||||||||
State: | IN | ||||||||
PostalCode: | 479035628 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7654484319 | ||||||||
FaxNumber: | 7654482921 | ||||||||
Practice Location | |||||||||
Address1: | 2400 SOUTH ST | ||||||||
Address2: |   | ||||||||
City: | LAFAYETTE | ||||||||
State: | IN | ||||||||
PostalCode: | 479043027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7654484319 | ||||||||
FaxNumber: | 7654482821 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2005 | ||||||||
LastUpdateDate: | 07/16/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 01030271A | IN | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | 111890E | 01 | IN | MEDICARE | OTHER | CA8380 | 01 | IN | RAIL ROAD MEDICARE | OTHER | 176600B | 01 | IN | MEDICARE | OTHER | 000000082506 | 01 | IN | ANTHEM | OTHER |