Basic Information
| Provider Information | |||||||||
| NPI: | 1679875389 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIRKX | ||||||||
| FirstName: | BEN | ||||||||
| MiddleName: | NICHOLAS | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 W 13 MILE RD | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480736712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488980161 | ||||||||
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| Practice Location | |||||||||
| Address1: | 401 E CARRILLO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931011460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055633307 | ||||||||
| FaxNumber: | 8055630998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2010 | ||||||||
| LastUpdateDate: | 08/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 5101018828 | MI | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | CA129679 | 01 | CA | NORTHERN MEDICARE PTAN | OTHER | CB220127 | 01 | CA | SOUTHERN MEDICARE PTAN | OTHER | 20A13373 | 01 | CA | MEDICAL BOARD LICENSE | OTHER |