Provider Demographics
NPI:1114976875
Name:DIRKS, SUSAN JEANNE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JEANNE
Last Name:DIRKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 SPRING STREET
Mailing Address - Street 2:CHC/SEIA
Mailing Address - City:COLUMBUS CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52737
Mailing Address - Country:US
Mailing Address - Phone:319-728-7400
Mailing Address - Fax:319-728-7404
Practice Address - Street 1:2409 SPRING STREET
Practice Address - Street 2:CHC/SEIA
Practice Address - City:COLUMBUS CITY
Practice Address - State:IA
Practice Address - Zip Code:52737
Practice Address - Country:US
Practice Address - Phone:319-728-7400
Practice Address - Fax:319-728-7404
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA41371207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF27585Medicare UPIN