Provider Demographics
NPI:1649596628
Name:BRISNEHAN, KIRK MATTHEW (DO)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:MATTHEW
Last Name:BRISNEHAN
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12234 PANAMA CITY BEACH PKWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-2725
Mailing Address - Country:US
Mailing Address - Phone:850-233-2323
Mailing Address - Fax:850-233-1055
Practice Address - Street 1:1455 W CHANDLER BLVD STE 4
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6177
Practice Address - Country:US
Practice Address - Phone:480-899-2900
Practice Address - Fax:833-973-4362
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12402207Q00000X
AZ010741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine