Basic Information
| Provider Information | |||||||||
| NPI: | 1437174984 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIRK | ||||||||
| FirstName: | JANET | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 N GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731071818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056326688 | ||||||||
| FaxNumber: | 4054295229 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 W ALAMEDA ST STE 25 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875011673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059888869 | ||||||||
| FaxNumber: | 5059826298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 11/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2296 | ME | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 4203 | OK | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200092960A | 05 | OK | MEDICAID |