Healthcare Provider Details

I. General information

NPI: 1275503161
Provider Name (Legal Business Name): DEAN KIRBY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 10/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S FARMERVILLE ST
RUSTON LA
71270-5941
US

IV. Provider business mailing address

1200 S FARMERVILLE ST
RUSTON LA
71270-5941
US

V. Phone/Fax

Practice location:
  • Phone: 318-251-6216
  • Fax:
Mailing address:
  • Phone: 318-251-6216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16431
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: