Basic Information
| Provider Information | |||||||||
| NPI: | 1427476225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIRKS | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1593 E POLSTON AVE | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082620945 | ||||||||
| FaxNumber: | 2084150150 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 N SYRINGA ST STE 205 | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082620945 | ||||||||
| FaxNumber: | 2084150150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2014 | ||||||||
| LastUpdateDate: | 09/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD193751 | OR | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | M-15190 | ID | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2136241 | 05 | WA | MEDICAID | 1427476225 | 05 | ID | MEDICAID |