Healthcare Provider Details

I. General information

NPI: 1578562146
Provider Name (Legal Business Name): LISA JOHNSON KIRK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 07/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 RICHLAND WEST CIRCLE SUITE A
WACO TX
76712-7919
US

IV. Provider business mailing address

318 RICHLAND WEST CIRCLE SUITE A
WACO TX
76712-7919
US

V. Phone/Fax

Practice location:
  • Phone: 254-776-8008
  • Fax: 254-776-6892
Mailing address:
  • Phone: 254-776-8008
  • Fax: 254-776-6892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberK3775
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: