Provider Demographics
NPI:1679875389
Name:DIRKX, BENJAMIN NICHOLAS (DO)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:NICHOLAS
Last Name:DIRKX
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 MESA DR
Mailing Address - Street 2:
Mailing Address - City:SOLVANG
Mailing Address - State:CA
Mailing Address - Zip Code:93463-2046
Mailing Address - Country:US
Mailing Address - Phone:517-896-9217
Mailing Address - Fax:
Practice Address - Street 1:401 E CARRILLO ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93101-1460
Practice Address - Country:US
Practice Address - Phone:805-563-3307
Practice Address - Fax:805-563-0998
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-01
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018828208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA129679OtherNORTHERN MEDICARE PTAN
CACB220127OtherSOUTHERN MEDICARE PTAN
CA20A13373OtherMEDICAL BOARD LICENSE