Provider Demographics
NPI:1871572990
Name:ERVELLI, DOMINICK C (DO)
Entity type:Individual
Prefix:
First Name:DOMINICK
Middle Name:C
Last Name:ERVELLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-8100
Mailing Address - Fax:515-643-8139
Practice Address - Street 1:800 E 1ST ST STE 1700
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-2100
Practice Address - Country:US
Practice Address - Phone:515-643-8100
Practice Address - Fax:515-643-8139
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03258207R00000X
IADO-03258207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1196071Medicaid
IA1196071Medicaid
IAG61284Medicare UPIN