Provider Demographics
NPI:1013902055
Name:DERKSEN, DIRK JON (MD)
Entity Type:Individual
Prefix:
First Name:DIRK
Middle Name:JON
Last Name:DERKSEN
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 1:10 WAGON WHEEL DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-9782
Mailing Address - Country:US
Mailing Address - Phone:920-731-6374
Mailing Address - Fax:
Practice Address - Street 1:10 WAGON WHEEL DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-9782
Practice Address - Country:US
Practice Address - Phone:920-731-6374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIAD6655394207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31145100Medicaid
WI31145100Medicaid