Provider Demographics
NPI:1053628933
Name:DR. MOHAMED IDRIS MEDICAL PC
Entity Type:Organization
Organization Name:DR. MOHAMED IDRIS MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:HUSSEIN
Authorized Official - Last Name:IDRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-582-8356
Mailing Address - Street 1:27 BALFOUR DR
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-5527
Mailing Address - Country:US
Mailing Address - Phone:516-538-0295
Mailing Address - Fax:516-538-0296
Practice Address - Street 1:55 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-2243
Practice Address - Country:US
Practice Address - Phone:516-538-0295
Practice Address - Fax:516-538-0296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228816207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty