Provider Demographics
NPI:1518946532
Name:ODDEN, KIRK M (MD)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:M
Last Name:ODDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8674
Mailing Address - Street 2:1230 E MAIN ST
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-8674
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:221 S MURPHY ST
Practice Address - Street 2:
Practice Address - City:LAKE CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:56055-2128
Practice Address - Country:US
Practice Address - Phone:507-726-2136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27361207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080068437OtherRR MEDICARE
MN3T990ODOtherBCBS
41084933956001C088OtherCHAMPUS
MNHP25875OtherHEALTH PARTNERS
MN080068437OtherRR MEDICARE
41084933956001C008OtherCHAMPUS
MN993067100Medicaid
MN0116026OtherMEDICA
1973693OtherIOWA MA
IA1973693Medicaid
IA95124OtherBCBS
MN26097OtherAMERICAS PPO
MN115441OtherUCARE
MNNA2951010486OtherPREFERRED ONE
MN0116026OtherMEDICA
MN3T990ODOtherBCBS