Healthcare Provider Details

I. General information

NPI: 1083879217
Provider Name (Legal Business Name): IMAD IDRISS MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2008
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2427 S TELSHOR BLVD
LAS CRUCES NM
88011-5049
US

IV. Provider business mailing address

2427 S TELSHOR BLVD
LAS CRUCES NM
88011-5049
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-1059
  • Fax: 575-522-3652
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number78-41
License Number StateNM

VIII. Authorized Official

Name: DR. IMAD IDRISS
Title or Position: PRESIDENT
Credential:
Phone: 575-522-1059