Provider Demographics
NPI:1477539302
Name:DERSAM, MICHAEL D (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:DERSAM
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 1:500 W. THOMAS ROAD, SUITE 850
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013
Mailing Address - Country:US
Mailing Address - Phone:602-406-2665
Mailing Address - Fax:602-212-4768
Practice Address - Street 1:500 W. THOMAS ROAD, SUITE 850
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013
Practice Address - Country:US
Practice Address - Phone:602-406-2669
Practice Address - Fax:602-406-8889
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30263174400000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ78550Medicare PIN
AZG80527Medicare UPIN