Healthcare Provider Details

I. General information

NPI: 1750887444
Provider Name (Legal Business Name): MUNIR H IDRISS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 FAIRVIEW AVE N STE 200
ROSEVILLE MN
55113-1306
US

IV. Provider business mailing address

2720 FAIRVIEW AVE N STE 200
ROSEVILLE MN
55113-1306
US

V. Phone/Fax

Practice location:
  • Phone: 651-633-6883
  • Fax: 651-331-3459
Mailing address:
  • Phone: 651-633-6883
  • Fax: 651-331-3459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number82274
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number66462
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: