=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982709697
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOUGLAS SCOTT KIRAR OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2006
-----------------------------------------------------
Last Update Date | 08/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2451 S SPRINGFIELD AVE WAL-MART VISION CENTER #0046
-----------------------------------------------------
City | BOLIRAR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-777-7662
-----------------------------------------------------
Fax | 417-777-6917
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 508 E PETTY LANE
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-276-6254
-----------------------------------------------------
Fax | 417-777-6917
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | MO2003025605
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------