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General NPI Number Information
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NPI Number | 1326308313
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Entity Type | Organization
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Legal Business Name | MOHAMMAD IDREES MD, P.A.
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Dates
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Enumeration Date | 05/23/2012
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Last Update Date | 05/23/2012
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Provider Practice Location Address
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Address Line | 1454 BELAIRE LANE N.E.
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City | PALM BAY
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State | FL
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Zip | 32905
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Country | US
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Telephone | 321-723-2121
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Fax | 321-723-7478
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Provider Business Mailing Address
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Address Line | 1454 BELAIRE LANE N.E.
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City | PALM BAY
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State | FL
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Zip | 32905
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Country | US
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Telephone | 321-723-2121
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Fax | 321-723-7478
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Authorized Official
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Title or Position | MEDICAL ASSISTANT
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Name | AMBER LEE TEDDER
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Credential |
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Telephone | 321-723-2121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | ME22385
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License Number State | FL
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