Healthcare Provider Details

I. General information

NPI: 1518167543
Provider Name (Legal Business Name): JOHN VINCENT KIRK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19600 E ROSS ST
TAHLEQUAH OK
74464-0545
US

IV. Provider business mailing address

19600 E ROSS ST
TAHLEQUAH OK
74464-0545
US

V. Phone/Fax

Practice location:
  • Phone: 539-234-4100
  • Fax: 539-234-4201
Mailing address:
  • Phone: 539-234-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP60394340
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4781
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2079922
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: