Healthcare Provider Details

I. General information

NPI: 1225142409
Provider Name (Legal Business Name): RUSSELL T DIRKSEN D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 E MONTCLAIR ST SUITE 100
SPRINGFIELD MO
65807-5068
US

IV. Provider business mailing address

929 E MONTCLAIR ST SUITE 100
SPRINGFIELD MO
65807-5068
US

V. Phone/Fax

Practice location:
  • Phone: 417-883-1881
  • Fax: 417-883-4844
Mailing address:
  • Phone: 417-883-1881
  • Fax: 417-883-4844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number695
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: