Provider Demographics
NPI:1104801802
Name:KIRKLAND, LISA (OD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:KIRKLAND
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 ELICE PL
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3903
Mailing Address - Country:US
Mailing Address - Phone:917-209-3713
Mailing Address - Fax:
Practice Address - Street 1:12221 GUY R BREWER BLVD # A
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-2406
Practice Address - Country:US
Practice Address - Phone:718-527-0550
Practice Address - Fax:718-527-0546
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT005701152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01608319Medicaid
NY4038240001Medicare NSC
NY03990Medicare PIN
NY01608319Medicaid