Provider Demographics
NPI:1518167543
Name:KIRK, JOHN VINCENT (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:VINCENT
Last Name:KIRK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19600 E ROSS ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-0545
Mailing Address - Country:US
Mailing Address - Phone:539-234-4100
Mailing Address - Fax:
Practice Address - Street 1:19600 E ROSS ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-0545
Practice Address - Country:US
Practice Address - Phone:539-234-4100
Practice Address - Fax:539-234-4201
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60394340207Q00000X
OK4781207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2079922Medicaid