Provider Demographics
NPI:1679570147
Name:DIRKSEN, JOHN STUART (MD)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:STUART
Last Name:DIRKSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:104 B SRP DR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3319
Mailing Address - Country:US
Mailing Address - Phone:706-210-8400
Mailing Address - Fax:706-210-8311
Practice Address - Street 1:104 B SRP DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3319
Practice Address - Country:US
Practice Address - Phone:706-210-8400
Practice Address - Fax:706-210-8311
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0337712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA260048595OtherRAILROAD MEDICARE
GA26BVDBQGMedicare ID - Type Unspecified
GAE41207Medicare UPIN