Provider Demographics
NPI:1821013913
Name:KIRN, EDWARD BRUCE (OD)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:BRUCE
Last Name:KIRN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7053
Mailing Address - Country:US
Mailing Address - Phone:207-783-9653
Mailing Address - Fax:207-782-3153
Practice Address - Street 1:249 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7053
Practice Address - Country:US
Practice Address - Phone:207-783-9653
Practice Address - Fax:207-782-3153
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT504152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1821013913Medicaid
ME240380099Medicaid
ME1821013913Medicaid
MET79568Medicare UPIN
T79568Medicare UPIN
ME704750Medicare PIN