Provider Demographics
NPI:1508857731
Name:DIERKS, STEPHEN M (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:M
Last Name:DIERKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 1327
Mailing Address - Street 2:
Mailing Address - City:LACONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03247-1327
Mailing Address - Country:US
Mailing Address - Phone:603-524-3211
Mailing Address - Fax:603-527-7038
Practice Address - Street 1:250 GREEN ST STE 104
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-1377
Practice Address - Country:US
Practice Address - Phone:978-669-5522
Practice Address - Fax:978-669-5521
Is Sole Proprietor?:No
Enumeration Date:2005-11-05
Last Update Date:2018-10-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA150601208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3157695Medicaid
MA3157695Medicaid
MAG28198Medicare UPIN