Provider Demographics
NPI:1174142343
Name:KIRK, DAVID ANDREW
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ANDREW
Last Name:KIRK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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:
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:2020-04-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS18762207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine