Basic Information
| Provider Information | |||||||||
| NPI: | 1871572990 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERVELLI | ||||||||
| FirstName: | DOMINICK | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1475 | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503051475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5156438100 | ||||||||
| FaxNumber: | 5156438139 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 E 1ST ST STE 1700 | ||||||||
| Address2: | |||||||||
| City: | ANKENY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500212100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5156438100 | ||||||||
| FaxNumber: | 5156438139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 03258 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | DO-03258 | IA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1196071 | 05 | IA | MEDICAID |