Healthcare Provider Details

I. General information

NPI: 1356564736
Provider Name (Legal Business Name): IAN T KIRSTE OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 10/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 S MAIN AVE
AZTEC NM
87410-2120
US

IV. Provider business mailing address

4323 E MAIN ST
FARMINGTON NM
87402-8621
US

V. Phone/Fax

Practice location:
  • Phone: 505-333-7278
  • Fax: 505-395-9287
Mailing address:
  • Phone: 505-326-7654
  • Fax: 505-356-7656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number424
License Number StateNM

VIII. Authorized Official

Name: DR. IAN T KIRSTE
Title or Position: OPTOMETRIST
Credential: OD
Phone: 505-326-7654