Provider Demographics
NPI:1427476225
Name:DIRKS, DEREK THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:THOMAS
Last Name:DIRKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-0945
Mailing Address - Fax:208-415-0150
Practice Address - Street 1:750 N SYRINGA ST STE 205
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5275
Practice Address - Country:US
Practice Address - Phone:208-262-0945
Practice Address - Fax:208-415-0150
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD193751208600000X, 208600000X
IDM-15190208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2136241Medicaid
ID1427476225Medicaid