Provider Demographics
NPI:1043606205
Name:KIRK, J WILLIAM (IDC)
Entity Type:Individual
Prefix:MR
First Name:J
Middle Name:WILLIAM
Last Name:KIRK
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIT 100331 BOX 1
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09513-3100
Mailing Address - Country:US
Mailing Address - Phone:757-443-8798
Mailing Address - Fax:
Practice Address - Street 1:34101 FARENHOLT AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-7000
Practice Address - Country:US
Practice Address - Phone:858-539-5507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman