Provider Demographics
NPI:1275556912
Name:IIDA, ERIC S (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:S
Last Name:IIDA
Suffix:
Gender:M
Credentials:MD
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 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:RENAL DIVISION
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-856-3156
Practice Address - Fax:508-856-3111
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA156090207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110005038AMedicaid
2674978OtherAETNA
P00072292OtherRAILROAD MEDICARE
156090OtherTUFTS
31-00209OtherUNITED HEALTHCARE
J22675OtherBC/BS
NH30008467Medicaid
000000006588OtherHEALTH NET PLAN
0020784OtherNEIGHBORHOOD HEALTH PLAN
MA0161624Medicaid
MA0161624Medicaid
0020784OtherNEIGHBORHOOD HEALTH PLAN