Provider Demographics
NPI:1215216874
Name:KIRK, TYLER E (OD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:E
Last Name:KIRK
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 1:423 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:CA
Mailing Address - Zip Code:95366-2425
Mailing Address - Country:US
Mailing Address - Phone:209-599-3115
Mailing Address - Fax:
Practice Address - Street 1:423 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:CA
Practice Address - Zip Code:95366-2425
Practice Address - Country:US
Practice Address - Phone:209-599-3115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14275152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFW163ZMedicare PIN