Provider Demographics
NPI:1699063941
Name:EDRISSIAN, MOHAMMADOMID (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMADOMID
Middle Name:
Last Name:EDRISSIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-1469
Mailing Address - Fax:
Practice Address - Street 1:222 ALEXANDER ST
Practice Address - Street 2:RHEUMATOLOGY
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-4039
Practice Address - Country:US
Practice Address - Phone:585-922-8350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA40781207RR0500X, 208M00000X
PAMD443871208M00000X
NY280630207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist