Provider Demographics
NPI:1992338057
Name:DIRKS, COREY M
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:M
Last Name:DIRKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:549 RIDGLEY RD
Mailing Address - Street 2:
Mailing Address - City:CROWNSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21032-1634
Mailing Address - Country:US
Mailing Address - Phone:443-223-2172
Mailing Address - Fax:
Practice Address - Street 1:549 RIDGLEY RD
Practice Address - Street 2:
Practice Address - City:CROWNSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21032-1634
Practice Address - Country:US
Practice Address - Phone:443-223-2172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program