Provider Demographics
NPI:1619962610
Name:KIRK, LAWRENCE F JR (MD)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:F
Last Name:KIRK
Suffix:JR
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 1:200 HIGHWAY 49 SOUTH
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:GA
Mailing Address - Zip Code:31008-6937
Mailing Address - Country:US
Mailing Address - Phone:478-956-2648
Mailing Address - Fax:478-956-4080
Practice Address - Street 1:200 HIGHWAY 49 SOUTH
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:GA
Practice Address - Zip Code:31008-6937
Practice Address - Country:US
Practice Address - Phone:478-956-2648
Practice Address - Fax:478-956-4080
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042072207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000772021JMedicaid
GAP00300958OtherRAILROAD MEDICARE
GAP00300958OtherRAILROAD MEDICARE
GAG71541Medicare UPIN