Healthcare Provider Details

I. General information

NPI: 1255580171
Provider Name (Legal Business Name): EUGENE BRENT KIRKLAND MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 06/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 FAR HILLS AVENUE
DAYTON OH
45429-2347
US

IV. Provider business mailing address

5300 FAR HILLS AVENUE
DAYTON OH
45429-2347
US

V. Phone/Fax

Practice location:
  • Phone: 937-291-8814
  • Fax: 937-433-4043
Mailing address:
  • Phone: 937-433-7536
  • Fax: 937-433-9612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35120684
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number35120684
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberMD445143
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number35120684
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: