Provider Demographics
NPI:1285607093
Name:KIRK, GREGORY A (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:A
Last Name:KIRK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:258 FORTENBERRY RD
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-3619
Mailing Address - Country:US
Mailing Address - Phone:321-848-0770
Mailing Address - Fax:321-848-0769
Practice Address - Street 1:258 FORTENBERRY RD
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-3619
Practice Address - Country:US
Practice Address - Phone:321-848-0770
Practice Address - Fax:321-848-0769
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL00567444207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE91536Medicare UPIN