Provider Demographics
NPI:1205930773
Name:DIRCKS, JOHN WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:DIRCKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:BOX 74
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-8481
Practice Address - Fax:269-341-7781
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJD028898207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI290C96034OtherBC/BS OF MICHIGAN
MIP54696OtherBLUECARE NETWORK
MI382356205105OtherCOMMUNITY CHOICE OF MICH
290C913410OtherBCBS GRP PIN
MI4830033OtherPHP
MI4991610Medicaid
4809116OtherPHP
290390908OtherBCBS IND PIN
108097OtherGRT LAKES HLTH PLAN
4379449OtherAETNA
MI1386445Medicaid
MI4830033OtherPHP
108097OtherGRT LAKES HLTH PLAN
290C913410OtherBCBS GRP PIN
MIC97618159Medicare PIN