Provider Demographics
NPI:1760503486
Name:IDRISS, SAMER IMAD (DO)
Entity Type:Individual
Prefix:
First Name:SAMER
Middle Name:IMAD
Last Name:IDRISS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9225 N 3RD ST
Mailing Address - Street 2:# 304
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2439
Mailing Address - Country:US
Mailing Address - Phone:602-445-0751
Mailing Address - Fax:602-424-8128
Practice Address - Street 1:9225 N 3RD ST
Practice Address - Street 2:# 304
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2439
Practice Address - Country:US
Practice Address - Phone:602-445-0751
Practice Address - Fax:602-424-8128
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ4469207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine