Healthcare Provider Details

I. General information

NPI: 1477997690
Provider Name (Legal Business Name): SAMIR DERISAVIFARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 EASTDALE AVE N
POUGHKEEPSIE NY
12603-1694
US

IV. Provider business mailing address

243 NORTH RD STE 304
POUGHKEEPSIE NY
12601-1173
US

V. Phone/Fax

Practice location:
  • Phone: 845-437-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number282292-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number282292-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: