Provider Demographics
NPI:1629280995
Name:IDRISS, REEDADA S (MD)
Entity Type:Individual
Prefix:
First Name:REEDADA
Middle Name:S
Last Name:IDRISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:REED
Other - Middle Name:S
Other - Last Name:IDRISS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5120 DUVALL PL NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-3821
Mailing Address - Country:US
Mailing Address - Phone:507-287-1831
Mailing Address - Fax:
Practice Address - Street 1:24 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6099
Practice Address - Country:US
Practice Address - Phone:203-739-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49753207P00000X
CT047400207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN297122100Medicaid
WI35174100Medicaid
IAENROLLEDMedicaid
IAENROLLEDMedicaid