Matilda Dervisevic, MD

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

2024024774 Issued in MO

Practice address

2401 Gillham Rd
Kansas City, MO 64108-4619

Phone

(816) 234-3000

Fax

(816) 302-9939

NPI assigned

Mar 19, 2024

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in MO

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1710806400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1724630400000",
    "number": "1649030768",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2401 GILLHAM RD",
            "city": "KANSAS CITY",
            "state": "MO",
            "postal_code": "641084619"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2401 GILLHAM RD",
            "city": "KANSAS CITY",
            "state": "MO",
            "postal_code": "641084619",
            "telephone_number": "816-234-3000",
            "fax_number": "816-302-9939"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DERVISEVIC",
        "first_name": "MATILDA",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2024-03-19",
        "last_updated": "2024-08-26",
        "certification_date": "2024-08-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "KS",
            "license": "94-11874",
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "MO",
            "license": "2024024774",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jamie Derleth, LPN
• Dermatology Specialists of Kansas City, P.C.
• Gretchen Gail Derr Mullins, MSAT
• Bruce James Derr, DDS
• Derrick Thomas Academy
• Al Des Marteau
• Aarsh Desai
• Gautam Desai, D.O.
• Komal B Desai, M.D.
• Lavina Vijay Desai, M.D.

• Pediatrics Physician in Kansas City, MO
• Providers in Kansas City, MO by specialty
• Pediatrics Physician in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 26, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.