Basic Information
| Provider Information | |||||||||
| NPI: | 1306882980 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIRK | ||||||||
| FirstName: | CLINT | ||||||||
| MiddleName: | FORREST | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 785 | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803579984 | ||||||||
| FaxNumber: | 5803573277 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 NW 31ST 2ND FLOOR | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803573671 | ||||||||
| FaxNumber: | 5803571256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 01/21/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 3331 | OK | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 5433409 | 01 | OK | FIRST HEALTH CCN | OTHER | 731612928 | 01 | OK | PPO OK | OTHER | P00007143 | 01 | OK | RR MEDICARE | OTHER | 8608608002 | 01 | OK | CIGNA PPO | OTHER | 731612928 | 01 | OK | COMPCHOICE | OTHER | 100169700B | 05 | OK | MEDICAID | 5433409 | 01 | OK | MAIL HANDLERS | OTHER | 2012060 | 01 | OK | FIRST HEALTH | OTHER | 731612928 | 01 | OK | BLUELINCS | OTHER | 731612928001 | 01 | OK | BC/BS | OTHER |