Provider Demographics
NPI:1740282755
Name:KIRBY, CHARLES A (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:KIRBY
Suffix:
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 1:5715 CORNELISON RD
Mailing Address - Street 2:6600 BLDG
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-5661
Mailing Address - Country:US
Mailing Address - Phone:423-892-3937
Mailing Address - Fax:423-892-5443
Practice Address - Street 1:5715 CORNELISON RD
Practice Address - Street 2:6600 BLDG
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-5661
Practice Address - Country:US
Practice Address - Phone:423-892-3937
Practice Address - Fax:423-892-5443
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2019-05-14
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
TNMD0000011473174400000X
TNMD00000011473207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3191743Medicaid
TN3191746Medicare ID - Type Unspecified
TN3191743Medicaid