MEDICARE: MR. JOHN STUART DIRKSEN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	033771	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	260048595	OTHER	GA	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1679570147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN STUART DIRKSEN MD

Provider Business Mailing Address
First Line	:	104 B SRP DR
Second Line	:
City	:	EVANS
State	:	GA
Zip	:	30809-3319
Country	:	US
Telephone Number	:	706-210-8400
Fax Number	:	706-210-8311

Provider Business Practice Location Address
First Line	:	104 B SRP DR
Second Line	:
City	:	EVANS
State	:	GA
Zip	:	30809-3319
Country	:	US
Telephone Number	:	706-210-8400
Fax Number	:	706-210-8311

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	10/03/2012

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