Provider Demographics
NPI:1255394573
Name:DIRKS, JAY ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:ALLEN
Last Name:DIRKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6600 EXCELSIOR BLVD STE 160
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-4713
Mailing Address - Country:US
Mailing Address - Phone:952-993-7700
Mailing Address - Fax:
Practice Address - Street 1:6600 EXCELSIOR BLVD STE 160
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426
Practice Address - Country:US
Practice Address - Phone:952-993-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43635207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN256R4DIOtherBCBS OF MN
MN171376OtherUCARE MN
MN116678600Medicaid
MN6605843OtherMEDICA UC
MN0113366OtherMEDICA
MN1029313OtherPREFERRED ONE
MNHP38689OtherHEALTHPARTNERS
MN1796988OtherAMERICA'S PPO
MN7402476OtherAETNA
MN6605843OtherMEDICA UC
MN1029313OtherPREFERRED ONE
MN171376OtherUCARE MN