Healthcare Provider Details

I. General information

NPI: 1902891096
Provider Name (Legal Business Name): KIRK C. MAYNARD OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16016 EVANS ST SUITE 101
OMAHA NE
68116-6457
US

IV. Provider business mailing address

16016 EVANS ST SUITE 101
OMAHA NE
68116-6457
US

V. Phone/Fax

Practice location:
  • Phone: 402-493-3224
  • Fax: 402-493-4041
Mailing address:
  • Phone: 402-493-3224
  • Fax: 402-493-4041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046007646
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1251
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: