Healthcare Provider Details

I. General information

NPI: 1225522212
Provider Name (Legal Business Name): INA DERVISHI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 05/10/2024
Certification Date: 05/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E DUNLAP AVE
PHOENIX AZ
85020-2825
US

IV. Provider business mailing address

111 E DUNLAP AVE STE I-279
PHOENIX AZ
85020-2807
US

V. Phone/Fax

Practice location:
  • Phone: 480-331-6721
  • Fax: 480-296-7738
Mailing address:
  • Phone: 480-331-6721
  • Fax: 480-296-7738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.071970
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number71267
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number71267
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number125071970
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number71267
License Number StateAZ
# 6
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number71267
License Number StateAZ
# 7
Primary TaxonomyY
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number71267
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: