Provider Demographics
NPI:1225522212
Name:DERVISHI, INA (MD)
Entity type:Individual
Prefix:
First Name:INA
Middle Name:
Last Name:DERVISHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E DUNLAP AVE STE I-279
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2807
Mailing Address - Country:US
Mailing Address - Phone:480-331-6721
Mailing Address - Fax:480-296-7738
Practice Address - Street 1:250 E DUNLAP AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2825
Practice Address - Country:US
Practice Address - Phone:480-331-6721
Practice Address - Fax:480-296-7738
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1250719702084N0400X
AZ712672084N0400X, 2084V0102X, 2084A2900X, 207RC0200X, 207T00000X
IL125.071970207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurocritical Care
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery