Provider Demographics
NPI:1962508366
Name:DIRKS, BRET A (MD)
Entity Type:Individual
Prefix:MR
First Name:BRET
Middle Name:A
Last Name:DIRKS
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 1:850 W IRONWOOD DR SUITE 300
Mailing Address - Street 2:
Mailing Address - City:COEUR DALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-667-1376
Mailing Address - Fax:208-292-0873
Practice Address - Street 1:850 W IRONWOOD DR SUITE 300
Practice Address - Street 2:
Practice Address - City:COEUR DALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-667-1376
Practice Address - Fax:208-292-0873
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6482207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID2741300Medicaid
1376455OtherMDC GROUP
1130111Medicare ID - Type Unspecified
ID2741300Medicaid