Provider Demographics
NPI:1861494700
Name:DUTTON, KIRK STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:STEVEN
Last Name:DUTTON
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 1:1316 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76701-1129
Mailing Address - Country:US
Mailing Address - Phone:254-776-1421
Mailing Address - Fax:254-776-1711
Practice Address - Street 1:1316 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76701-1129
Practice Address - Country:US
Practice Address - Phone:254-776-1421
Practice Address - Fax:254-776-1711
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE96132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX034725401Medicaid
TX282857OtherVALUE OPTIONS
TX007250000OtherMAGELLAN BEHAVIORAL
TX000000LM23OtherBCBS OF TEXAS
TX034725401Medicaid
TX000000LM23OtherBCBS OF TEXAS