Provider Demographics
NPI:1386717783
Name:DARVISH, AMIR HOOTAN (MD)
Entity type:Individual
Prefix:
First Name:AMIR
Middle Name:HOOTAN
Last Name:DARVISH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331B PERKINS ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4003
Mailing Address - Country:US
Mailing Address - Phone:917-804-5628
Mailing Address - Fax:
Practice Address - Street 1:750 WASHINGTON STREET
Practice Address - Street 2:DEPT OF EMERGENCY MEDICINE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111
Practice Address - Country:US
Practice Address - Phone:617-636-4720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225767207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02321153Medicaid
NY02321153Medicaid
NY781V31Medicare ID - Type Unspecified