Provider Demographics
NPI:1366640377
Name:DIRKS, ZACHARY BLAKE (OD)
Entity type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:BLAKE
Last Name:DIRKS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:320 SUNRISE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-1352
Mailing Address - Country:US
Mailing Address - Phone:507-931-6436
Mailing Address - Fax:504-934-9625
Practice Address - Street 1:320 SUNRISE DR
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-1352
Practice Address - Country:US
Practice Address - Phone:507-931-6436
Practice Address - Fax:504-934-9625
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3080152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN44977THOtherBLUE PLUS EYEWEAR/CARE
MN1366640377OtherIOWA MEDICAID
MN1366640377OtherMEDICA
MN139494OtherUCARE
MN076N5DIOtherBCBS
MNHP82001OtherHEALTH PARTNERS
MN1051614OtherPREFERRED ONE
MN0322460001OtherDMERC
MN2116066OtherMEDICA EYEWEAR/CARE
MN0322460001OtherDMERC