Provider Demographics
NPI:1093838575
Name:KIRK, DANIEL WAYNE (DPM)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:WAYNE
Last Name:KIRK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:OH
Mailing Address - Zip Code:45817-1246
Mailing Address - Country:US
Mailing Address - Phone:419-358-3050
Mailing Address - Fax:419-358-0240
Practice Address - Street 1:148 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:OH
Practice Address - Zip Code:45817-1246
Practice Address - Country:US
Practice Address - Phone:419-358-3050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003451213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2786178Medicaid
OH2786178Medicaid
OHP00852945Medicare PIN