NPIMap

Individual provider Active NPI

Mohammad Idris, M.D.

  • Family Medicine Physician
  • Van Buren, AR
National Provider Identifier
1407086200
Registry record updated Sep 13, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
E7605 Issued in AR
Practice address
14 Gothic Ridge Rd
Van Buren, AR 72956-6565
Phone
(479) 471-0011
Fax
(479) 471-1960
NPI assigned
Jul 15, 2009
Last updated
Sep 13, 2012By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 13, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Student in an Organized Health Care Education/Training Program 390200000X NU
Family Medicine Physician 207Q00000X E7605 AR Primary

Addresses

Primary practice location

14 Gothic Ridge Rd
Van Buren, AR 72956-6565

Mailing address

PO Box 405981
Atlanta, GA 30384-5981
Phone (479) 709-7399

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20121003000809 AR Practitioner - Family Practice 4789833997 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2002
Medicare assignment
Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

816 1St Ave
Suite a
Conway, AR 72032-5716
Phone (501) 358-6990

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Providence Family Medicine Clinic Inc Family Medicine CurrentSince Sep 1, 2018 Accepting new patients

Locations

816 1st Ave
Ste A
Conway, AR 72032
Phone (501) 358-6990

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/GHDFBD/Endpoint/GHDFBD

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 8

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1247616000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1347494400000",
    "number": "1407086200",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 405981",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303845981",
            "telephone_number": "479-709-7399",
            "fax_number": "479-709-7053"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "14 GOTHIC RIDGE RD",
            "city": "VAN BUREN",
            "state": "AR",
            "postal_code": "729566565",
            "telephone_number": "479-471-0011",
            "fax_number": "479-471-1960"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "IDRIS",
        "first_name": "MOHAMMAD",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2009-07-15",
        "last_updated": "2012-09-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "AR",
            "license": "E7605",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Van Buren, AR

Sources for this page

Verify at the official NPI Registry.