Healthcare Provider Details

I. General information

NPI: 1639613276
Provider Name (Legal Business Name): CHARLES RICHARD KIRK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5323 HARRY HINES BOULEVARD
DALLAS TX
75390-7208
US

IV. Provider business mailing address

PO BOX 845347
DALLAS TX
75284-5347
US

V. Phone/Fax

Practice location:
  • Phone: 214-456-2533
  • Fax: 214-456-8130
Mailing address:
  • Phone: 214-456-2533
  • Fax: 214-456-8130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number45647
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: