Provider Demographics
NPI:1477675940
Name:DIERKING, JASON MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:MICHAEL
Last Name:DIERKING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-3027
Mailing Address - Country:US
Mailing Address - Phone:712-213-4750
Mailing Address - Fax:712-213-5230
Practice Address - Street 1:210 E 5TH ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-2342
Practice Address - Country:US
Practice Address - Phone:712-213-4750
Practice Address - Fax:712-213-5230
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA37099208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0786335Medicaid
IAI20603Medicare PIN