Healthcare Provider Details

I. General information

NPI: 1407086200
Provider Name (Legal Business Name): MOHAMMAD IDRIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 GOTHIC RIDGE RD
VAN BUREN AR
72956-6565
US

IV. Provider business mailing address

PO BOX 405981
ATLANTA GA
30384-5981
US

V. Phone/Fax

Practice location:
  • Phone: 479-471-0011
  • Fax: 479-471-1960
Mailing address:
  • Phone: 479-709-7399
  • Fax: 479-709-7053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE7605
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: