Healthcare Provider Details

I. General information

NPI: 1427476225
Provider Name (Legal Business Name): DEREK THOMAS DIRKS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 N SYRINGA ST STE 205
POST FALLS ID
83854-5275
US

IV. Provider business mailing address

1593 E POLSTON AVE
POST FALLS ID
83854-5326
US

V. Phone/Fax

Practice location:
  • Phone: 208-262-0945
  • Fax: 208-415-0150
Mailing address:
  • Phone: 208-262-0945
  • Fax: 208-415-0150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD193751
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM-15190
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: