Healthcare Provider Details

I. General information

NPI: 1437111085
Provider Name (Legal Business Name): MUSTAFA SECKIN DERVISH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 MADISON ST GOUVERNEUR MEDICAL STAFF OFFICE, ROOM 1249
NEW YORK NY
10002-7537
US

IV. Provider business mailing address

120 CENTRAL PARK S 3D
NEW YORK NY
10019-1560
US

V. Phone/Fax

Practice location:
  • Phone: 212-238-7614
  • Fax: 212-238-7009
Mailing address:
  • Phone: 212-245-8973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number125039
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125039
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: