Healthcare Provider Details

I. General information

NPI: 1609196245
Provider Name (Legal Business Name): KIRK MEDICAL INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2010
Last Update Date: 08/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 WILSON TER SUITE 220
GLENDALE CA
91206-4071
US

IV. Provider business mailing address

1505 WILSON TER SUITE 220
GLENDALE CA
91206-4071
US

V. Phone/Fax

Practice location:
  • Phone: 818-241-6132
  • Fax: 818-241-6124
Mailing address:
  • Phone: 818-241-6132
  • Fax: 818-241-6124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberA54807
License Number StateCA

VIII. Authorized Official

Name: JOHN HOWARTH KIRK III
Title or Position: PRESIDENT/CEO
Credential: M.D.
Phone: 818-241-6132