Provider Demographics
NPI:1629145057
Name:DIRKS, BLAKE THOMAS (OD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:THOMAS
Last Name:DIRKS
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 1:320 SUNRISE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-1352
Mailing Address - Country:US
Mailing Address - Phone:507-931-6436
Mailing Address - Fax:507-934-9625
Practice Address - Street 1:320 SUNRISE DR
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-1352
Practice Address - Country:US
Practice Address - Phone:507-931-6436
Practice Address - Fax:507-934-9625
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2076152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1D065DIOtherBCBS
410005042OtherRAILROAD MEDICARE
0582866OtherIOWA MA
1001626OtherPREFERRED ONE
44977THOtherBLUE PLUS EYEWEAR
21 16066OtherEYEWEAR MEDICA
22 12052OtherMEDICA
MN114330OtherUCARE
MN228223200Medicaid
MNHP28649OtherHEALTH PARTNERS
0322460001OtherDMERC
MN0322460001Medicare NSC
1001626OtherPREFERRED ONE
22 12052OtherMEDICA