Provider Demographics
NPI:1467441253
Name:DERKEVORKIAN, NAZARET (MD)
Entity Type:Individual
Prefix:DR
First Name:NAZARET
Middle Name:
Last Name:DERKEVORKIAN
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 1:323 LOWELL ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-4501
Mailing Address - Country:US
Mailing Address - Phone:978-783-5000
Mailing Address - Fax:978-313-8184
Practice Address - Street 1:323 LOWELL ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-4501
Practice Address - Country:US
Practice Address - Phone:978-783-5000
Practice Address - Fax:978-313-8184
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216431207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ26493OtherBC.BS
MA1301853Medicaid
MA1301853Medicaid