Provider Demographics
NPI:1902891096
Name:MAYNARD, KIRK C (OD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:C
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:16016 EVANS ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-6457
Mailing Address - Country:US
Mailing Address - Phone:402-493-3224
Mailing Address - Fax:402-493-4041
Practice Address - Street 1:16016 EVANS ST
Practice Address - Street 2:SUITE 101
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68116-6457
Practice Address - Country:US
Practice Address - Phone:402-493-3224
Practice Address - Fax:402-493-4041
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007646152W00000X
NE1251152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47048659410Medicaid
NEP00932191Medicare PIN
NE47048659410Medicaid