Healthcare Provider Details

I. General information

NPI: 1124730874
Provider Name (Legal Business Name): ISRA IDRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2022
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN ST
DETROIT MI
48201-2119
US

IV. Provider business mailing address

3800 WOODWARD AVE APT 306
DETROIT MI
48201-1978
US

V. Phone/Fax

Practice location:
  • Phone: 571-484-2860
  • Fax:
Mailing address:
  • Phone: 571-484-2860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: