Provider Demographics
NPI:1144330556
Name:KIRK, ANTHONY J (DPM PC)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:KIRK
Suffix:
Gender:M
Credentials:DPM PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 BRETON RD SE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5547
Mailing Address - Country:US
Mailing Address - Phone:616-949-1524
Mailing Address - Fax:616-949-9472
Practice Address - Street 1:2050 BRETON RD SE
Practice Address - Street 2:SUITE 105
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5547
Practice Address - Country:US
Practice Address - Phone:616-949-1524
Practice Address - Fax:616-949-9472
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAK400050213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4355335Medicaid
4854111170OtherBCBS
4854111170OtherBCBS
T34010Medicare UPIN
MI5415006Medicare ID - Type Unspecified