Provider Demographics
NPI:1265443634
Name:KIRKPATRICK, ROBERT WAYNE (OD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:WAYNE
Last Name:KIRKPATRICK
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 1:2580 MICHIGAN RD
Mailing Address - Street 2:STE 2
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-2423
Mailing Address - Country:US
Mailing Address - Phone:812-265-6222
Mailing Address - Fax:812-265-2955
Practice Address - Street 1:2580 MICHIGAN RD
Practice Address - Street 2:STE 2
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-2423
Practice Address - Country:US
Practice Address - Phone:812-265-6222
Practice Address - Fax:812-265-2955
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001749152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100148580Medicaid
IN000000042676OtherANTHEM
005398OtherSIHO
410047137OtherRAILROAD MEDICARE
QMXPR0070032OtherMOLINA
IN351957465050OtherCARESOURCE
IN000000042676OtherANTHEM
IN1162510001Medicare NSC
IN100148580Medicaid