Healthcare Provider Details

I. General information

NPI: 1205936853
Provider Name (Legal Business Name): JARED J DIRKS MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 S MAIN ST
CONCORDIA MO
64020-8335
US

IV. Provider business mailing address

905 S MAIN ST
CONCORDIA MO
64020-8335
US

V. Phone/Fax

Practice location:
  • Phone: 660-463-7966
  • Fax: 660-463-7729
Mailing address:
  • Phone: 660-463-7966
  • Fax: 660-463-7729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2005037602
License Number StateMO

VIII. Authorized Official

Name: JARED JAY DIRKS
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 660-463-7966