Provider Demographics
NPI:1104854462
Name:DERVISH, AHMET (MD)
Entity type:Individual
Prefix:
First Name:AHMET
Middle Name:
Last Name:DERVISH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:AHMET
Other - Middle Name:
Other - Last Name:DERVISOGULLARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2845 GREENBRIER RD STE 340
Mailing Address - Street 2:PO BOX 8900
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54308-8900
Mailing Address - Country:US
Mailing Address - Phone:920-288-8380
Mailing Address - Fax:920-288-8385
Practice Address - Street 1:2845 GREENBRIER RD STE 340
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-8380
Practice Address - Fax:920-288-8385
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33794208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104365449Medicaid
WI050080452OtherRAILROAD
WI32021400Medicaid
WI013407650Medicare ID - Type Unspecified
WI32021400Medicaid