Provider Demographics
NPI:1053585943
Name:LISA KIRKLAND OD PC
Entity type:Organization
Organization Name:LISA KIRKLAND OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:T
Authorized Official - Last Name:KIRKLAND
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-527-0550
Mailing Address - Street 1:830 ELICE PL
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3903
Mailing Address - Country:US
Mailing Address - Phone:917-209-3713
Mailing Address - Fax:
Practice Address - Street 1:12221A GUY R BREWER BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-2406
Practice Address - Country:US
Practice Address - Phone:718-527-0550
Practice Address - Fax:718-527-0546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT005701261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01608319Medicaid
NYG400009269Medicare PIN
NY01608319Medicaid