Provider Demographics
NPI:1770546657
Name:KIRSTE, IAN THORSTEN (OD)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:THORSTEN
Last Name:KIRSTE
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 1:121 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-2120
Mailing Address - Country:US
Mailing Address - Phone:505-333-7278
Mailing Address - Fax:505-395-9287
Practice Address - Street 1:121 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-2120
Practice Address - Country:US
Practice Address - Phone:505-333-7278
Practice Address - Fax:505-395-9287
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM424152WV0400X, 152WX0102X, 152W00000X, 152WC0802X, 152WL0500X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM23623331Medicaid
NM23623331Medicaid
NM246711403Medicare PIN