Provider Demographics
NPI:1679683627
Name:KIRK, JOHN H III (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:KIRK
Suffix:III
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8419
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39535-8087
Mailing Address - Country:US
Mailing Address - Phone:228-388-5714
Mailing Address - Fax:228-388-0017
Practice Address - Street 1:394 COURTHOUSE RD
Practice Address - Street 2:SUITE B
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-1865
Practice Address - Country:US
Practice Address - Phone:228-896-1189
Practice Address - Fax:228-896-9989
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3606225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1033218524OtherGROUP NPI
MS09015077Medicaid
MSC02726Medicare UPIN