Provider Demographics
NPI:1093868606
Name:MAHAN, KIRK NORWOOD (OD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:NORWOOD
Last Name:MAHAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 E HAYMARKET WAY
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-4671
Mailing Address - Country:US
Mailing Address - Phone:330-342-9846
Mailing Address - Fax:
Practice Address - Street 1:7969 W RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-5516
Practice Address - Country:US
Practice Address - Phone:440-884-3090
Practice Address - Fax:440-884-1046
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2021-03-02
Deactivation Date:2021-02-22
Deactivation Code:
Reactivation Date:2021-03-02
Provider Licenses
StateLicense IDTaxonomies
OH3839152W00000X
PAOE007297P152W00000X
TX03419152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34-1569066OtherFORMER TAX ID
OH203287006OtherTAX ID