Provider Demographics
NPI:1265565907
Name:STARK, KEITH BRADLEY (PT, DPT)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:BRADLEY
Last Name:STARK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7440 TRANSOM CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-5870
Mailing Address - Country:US
Mailing Address - Phone:813-404-3799
Mailing Address - Fax:727-789-0716
Practice Address - Street 1:33100 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3127
Practice Address - Country:US
Practice Address - Phone:727-789-6008
Practice Address - Fax:727-789-0716
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21717225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist