Healthcare Provider Details

I. General information

NPI: 1295672731
Provider Name (Legal Business Name): FATEN SID IDRIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 ALBANY ST RM 637
BOSTON MA
02118-2646
US

IV. Provider business mailing address

6 SHERBONE PL
SAYREVILLE NJ
08872-1369
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-5591
  • Fax:
Mailing address:
  • Phone: 617-414-5591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number0000-0003-4231-7500
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: