Provider Demographics
NPI:1326046152
Name:KIERNAN, JOHN D (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:KIERNAN
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 1:1214 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51105-1417
Mailing Address - Country:US
Mailing Address - Phone:712-252-4406
Mailing Address - Fax:712-252-5296
Practice Address - Street 1:1214 PIERCE ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51105-1417
Practice Address - Country:US
Practice Address - Phone:712-252-4406
Practice Address - Fax:712-252-5296
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1687152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA178012Medicaid
IA178012Medicaid
IATO1023Medicare UPIN
IA410012212Medicare PIN