Provider Demographics
NPI:1295863371
Name:KIRK, JOHN MARK (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARK
Last Name:KIRK
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:2241 THORNTON TAYLOR PKWY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-3637
Mailing Address - Country:US
Mailing Address - Phone:256-260-7306
Mailing Address - Fax:256-350-1661
Practice Address - Street 1:1315 13TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4308
Practice Address - Country:US
Practice Address - Phone:256-260-7306
Practice Address - Fax:256-350-1661
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN17132084P0804X
ALDO 2312084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000010902Medicare ID - Type Unspecified
ALH73093Medicare UPIN