Provider Demographics
NPI:1902132434
Name:DIERKS, MARTIN LEE JR (IDC)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:LEE
Last Name:DIERKS
Suffix:JR
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2915 PARTHENON DR
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:MO
Mailing Address - Zip Code:63020-4645
Mailing Address - Country:US
Mailing Address - Phone:757-650-8436
Mailing Address - Fax:
Practice Address - Street 1:2915 PARTHENON DR
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-4645
Practice Address - Country:US
Practice Address - Phone:757-650-8436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-17
Last Update Date:2009-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman