Provider Demographics
NPI:1508054842
Name:WEST KIRK MEDICAL PRACTICE, PA
Entity Type:Organization
Organization Name:WEST KIRK MEDICAL PRACTICE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:LEONEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-227-9408
Mailing Address - Street 1:711 KIRK PL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78226-1416
Mailing Address - Country:US
Mailing Address - Phone:210-227-9408
Mailing Address - Fax:
Practice Address - Street 1:711 KIRK PL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78226-1416
Practice Address - Country:US
Practice Address - Phone:210-227-9408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7516261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168296501Medicaid
TX112094102Medicaid
TX5903OtherAETNA
TX112094104Medicaid
TX112094101Medicaid
TX8K1570OtherBCBS
TX112094103Medicaid
TX5903OtherAETNA
TX8K1570OtherBCBS