Healthcare Provider Details

I. General information

NPI: 1477539302
Provider Name (Legal Business Name): MICHAEL D DERSAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 E HIGHLAND AVE STE 425
PHOENIX AZ
85016-4881
US

IV. Provider business mailing address

2500 W UTOPIA RD STE 100
PHOENIX AZ
85027-4172
US

V. Phone/Fax

Practice location:
  • Phone: 602-588-4040
  • Fax: 602-588-4034
Mailing address:
  • Phone: 623-683-4463
  • Fax: 623-683-4963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number30263
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number30263
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: