Provider Demographics
NPI:1457416190
Name:KIRK, DUANE IVAN (OD)
Entity Type:Individual
Prefix:
First Name:DUANE
Middle Name:IVAN
Last Name:KIRK
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 1:423 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:CA
Mailing Address - Zip Code:95366-2425
Mailing Address - Country:US
Mailing Address - Phone:209-599-3115
Mailing Address - Fax:209-599-3793
Practice Address - Street 1:423 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:CA
Practice Address - Zip Code:95366-2425
Practice Address - Country:US
Practice Address - Phone:209-599-3115
Practice Address - Fax:209-599-3793
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6477T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0064771Medicaid
CASD0064771Medicaid
CAT10332Medicare UPIN
CASD0064770Medicare PIN