Provider Demographics
NPI:1720082233
Name:KIRKLAND, LEVI S JR (MD)
Entity Type:Individual
Prefix:
First Name:LEVI
Middle Name:S
Last Name:KIRKLAND
Suffix:JR
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:P O BOX 6193
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63006-6193
Mailing Address - Country:US
Mailing Address - Phone:314-644-1411
Mailing Address - Fax:314-644-1606
Practice Address - Street 1:1034 S BRENTWOOD BLVD
Practice Address - Street 2:SUITE 694
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1223
Practice Address - Country:US
Practice Address - Phone:314-644-1411
Practice Address - Fax:314-644-1606
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095002208600000X
MOR9J09208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL265870Medicare PIN
ILE14105Medicare UPIN
MO000005826Medicare PIN