Healthcare Provider Details

I. General information

NPI: 1689654063
Provider Name (Legal Business Name): KIRK FLYNN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 10/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 N MIDDLETOWN RD 2B
PEARL RIVER NY
10965-1188
US

IV. Provider business mailing address

275 N MIDDLETOWN RD 2B
PEARL RIVER NY
10965-1188
US

V. Phone/Fax

Practice location:
  • Phone: 845-735-5757
  • Fax:
Mailing address:
  • Phone: 845-735-5757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5469
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: