Provider Demographics
NPI:1891919312
Name:IDRIS, SHADI (MD)
Entity type:Individual
Prefix:DR
First Name:SHADI
Middle Name:
Last Name:IDRIS
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 1:1717 SHAFFER ST
Mailing Address - Street 2:SUITE 002
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1623
Mailing Address - Country:US
Mailing Address - Phone:269-552-2823
Mailing Address - Fax:269-552-2964
Practice Address - Street 1:1717 SHAFFER ST
Practice Address - Street 2:SUITE 002
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1623
Practice Address - Country:US
Practice Address - Phone:269-552-2823
Practice Address - Fax:269-552-2964
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ54455207RC0000X, 207RC0001X
MI4301085994207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology