Healthcare Provider Details

I. General information

NPI: 1750456448
Provider Name (Legal Business Name): GARY MARK KIRK M.D., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3332 GLACIER RIDGE RD
MIDDLETON WI
53562-1769
US

IV. Provider business mailing address

3332 GLACIER RIDGE RD
MIDDLETON WI
53562-1769
US

V. Phone/Fax

Practice location:
  • Phone: 616-485-3271
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number67490-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: