Provider Demographics
NPI:1992324545
Name:DIERKER, THERESA MARIE (DO)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:DIERKER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD # 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1952
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:25631 LITTLE MACK AVE STE 103
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-2100
Practice Address - Country:US
Practice Address - Phone:586-443-2333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101027062207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine