Provider Demographics
NPI:1740286152
Name:KIRKHAM, WAYNE R (MD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:R
Last Name:KIRKHAM
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 1:7777 FOREST LN
Mailing Address - Street 2:STE C506
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-6845
Mailing Address - Country:US
Mailing Address - Phone:972-566-7515
Mailing Address - Fax:972-566-7067
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:STE C506
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-6845
Practice Address - Country:US
Practice Address - Phone:972-566-7515
Practice Address - Fax:972-566-7067
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7636174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBM60Medicaid
TX00BM60Medicare PIN
TXBM60Medicaid