Basic Information
| Provider Information | |||||||||
| NPI: | 1386717783 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DARVISH | ||||||||
| FirstName: | AMIR | ||||||||
| MiddleName: | HOOTAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 331B PERKINS ST | ||||||||
| Address2: | |||||||||
| City: | JAMAICA PLAIN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021304003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9178045628 | ||||||||
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| Practice Location | |||||||||
| Address1: | 750 WASHINGTON STREET | ||||||||
| Address2: | DEPT OF EMERGENCY MEDICINE | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176364720 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 09/10/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 225767 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02321153 | 05 | NY | MEDICAID |