Healthcare Provider Details

I. General information

NPI: 1689061830
Provider Name (Legal Business Name): EVGENY IDRISOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 07/05/2022
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 S TAMIAMI TRL
SARASOTA FL
34239
US

IV. Provider business mailing address

PO BOX 863407
ORLANDO FL
32886-3407
US

V. Phone/Fax

Practice location:
  • Phone: 941-917-4896
  • Fax: 941-917-6884
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME131245
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME131245
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberPENDING
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberTRN21341
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: