Provider Demographics
NPI:1376551457
Name:SCULLION, KIRBY L (OD)
Entity Type:Individual
Prefix:
First Name:KIRBY
Middle Name:L
Last Name:SCULLION
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 1:2379 17TH ST SE
Mailing Address - Street 2:
Mailing Address - City:EAST CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44730-9542
Mailing Address - Country:US
Mailing Address - Phone:330-452-1597
Mailing Address - Fax:330-479-9752
Practice Address - Street 1:4004 TUSCARAWAS ST W
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-5503
Practice Address - Country:US
Practice Address - Phone:330-479-9750
Practice Address - Fax:330-479-9752
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2013-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3495/T1636152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0442239Medicaid
SC4130732Medicare ID - Type Unspecified
T47307Medicare UPIN