Provider Demographics
NPI:1215911698
Name:KIRSE, DANIEL JEFFREY (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JEFFREY
Last Name:KIRSE
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-713-4580
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-713-4580
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200200559207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
7494649OtherAETNA
NC131FTOtherBCBS
SCQ0055GMedicaid
VA6737161Medicaid
NC89131FTMedicaid
NCB7060OtherMEDCOST
WV2005965000Medicaid
NC49043OtherPARTNERS
NC2006859Medicare PIN
NCB7060OtherMEDCOST