Provider Demographics
NPI:1619071024
Name:KIRK, MARVIN NORWOOD (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:NORWOOD
Last Name:KIRK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 B WEST SOUTH STREET
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-4066
Mailing Address - Country:US
Mailing Address - Phone:501-776-8545
Mailing Address - Fax:501-776-1619
Practice Address - Street 1:1102 B W. SOUTH STREET
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-4066
Practice Address - Country:US
Practice Address - Phone:501-776-8545
Practice Address - Fax:501-776-1619
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4039207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARC4039OtherSTATE LISCENCE
ARC68662Medicare UPIN
ARC4039OtherSTATE LISCENCE