Provider Demographics
NPI:1326308313
Name:MOHAMMAD IDREES MD, P.A.
Entity Type:Organization
Organization Name:MOHAMMAD IDREES MD, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:TEDDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-723-2121
Mailing Address - Street 1:1454 BELAIRE LANE N.E.
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905
Mailing Address - Country:US
Mailing Address - Phone:321-723-2121
Mailing Address - Fax:321-723-7478
Practice Address - Street 1:1454 BELAIRE LANE N.E.
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905
Practice Address - Country:US
Practice Address - Phone:321-723-2121
Practice Address - Fax:321-723-7478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME22385207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL#054484100Medicaid
FL#31072Medicare PIN
FL#054484100Medicaid