Provider Demographics
NPI:1578562146
Name:KIRK, LISA JOHNSON (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JOHNSON
Last Name:KIRK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 RICHLAND WEST CIRCLE
Mailing Address - Street 2:SUITE A
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-7919
Mailing Address - Country:US
Mailing Address - Phone:254-776-8008
Mailing Address - Fax:254-776-6892
Practice Address - Street 1:318 RICHLAND WEST CIRCLE
Practice Address - Street 2:SUITE A
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7919
Practice Address - Country:US
Practice Address - Phone:254-776-8008
Practice Address - Fax:254-776-6892
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3775207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092305403Medicaid
TXG52439Medicare UPIN
TX811586Medicare PIN