Provider Demographics
NPI:1245206648
Name:PRODZINSKI, KIRK D (DO)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:D
Last Name:PRODZINSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-5420
Mailing Address - Country:US
Mailing Address - Phone:208-642-9376
Mailing Address - Fax:208-642-9598
Practice Address - Street 1:207 E 12TH ST
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-3626
Practice Address - Country:US
Practice Address - Phone:208-365-1065
Practice Address - Fax:208-365-1068
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41285207Q00000X
MN42041207Q00000X
IA04555207Q00000X
IDO-0600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH06804Medicare UPIN