Provider Demographics
NPI:1043226889
Name:CHRISTY, ILIA JL (MD)
Entity Type:Individual
Prefix:DR
First Name:ILIA
Middle Name:JL
Last Name:CHRISTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ILIA
Other - Middle Name:
Other - Last Name:WAKEHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4011 FANUEL ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5207
Mailing Address - Country:US
Mailing Address - Phone:626-755-7409
Mailing Address - Fax:
Practice Address - Street 1:3811 VALLEY CENTRE DR
Practice Address - Street 2:S99
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3318
Practice Address - Country:US
Practice Address - Phone:858-764-3000
Practice Address - Fax:858-764-3025
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85980207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics