Provider Demographics
NPI:1134283567
Name:DIERCKS, MARK J (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
Last Name:DIERCKS
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1111 NORTH 13TH STREET
Mailing Address - Street 2:SUITE 207
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68102-4251
Mailing Address - Country:US
Mailing Address - Phone:402-348-1996
Mailing Address - Fax:402-348-1879
Practice Address - Street 1:1111 NORTH 13TH STREET
Practice Address - Street 2:SUITE 207
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-4251
Practice Address - Country:US
Practice Address - Phone:402-348-1996
Practice Address - Fax:402-348-1879
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2019-03-21
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Provider Licenses
StateLicense IDTaxonomies
NE161372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47068181100Medicaid
F07499Medicare UPIN
NE47068181100Medicaid