Provider Demographics
NPI:1174669899
Name:DIRKSEN, ROBERT B (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:B
Last Name:DIRKSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5357
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93403-5357
Mailing Address - Country:US
Mailing Address - Phone:805-545-7881
Mailing Address - Fax:805-548-8785
Practice Address - Street 1:3855 BROAD STREET
Practice Address - Street 2:SUITE B
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401
Practice Address - Country:US
Practice Address - Phone:805-545-7881
Practice Address - Fax:805-548-8785
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12172152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist