Provider Demographics
NPI:1437111085
Name:DERVISH, MUSTAFA SECKIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MUSTAFA
Middle Name:SECKIN
Last Name:DERVISH
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 1:120 CENTRAL PARK S
Mailing Address - Street 2:3D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1560
Mailing Address - Country:US
Mailing Address - Phone:212-245-8973
Mailing Address - Fax:
Practice Address - Street 1:227 MADISON ST
Practice Address - Street 2:GOUVERNEUR MEDICAL STAFF OFFICE, ROOM 1249
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7537
Practice Address - Country:US
Practice Address - Phone:212-238-7614
Practice Address - Fax:212-238-7009
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125039208200000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400006987Medicare PIN
NY39H6420781Medicare PIN