Provider Demographics
NPI:1215656053
Name:IDRIES, IYAD YOUSEF MOHAMMAD
Entity type:Individual
Prefix:
First Name:IYAD
Middle Name:YOUSEF MOHAMMAD
Last Name:IDRIES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 E 94TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-1621
Mailing Address - Country:US
Mailing Address - Phone:347-715-8901
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKDALE PLZ
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-3139
Practice Address - Country:US
Practice Address - Phone:347-715-8901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program