Provider Demographics
NPI:1073005484
Name:ILYASOVA, IRYNA (MD)
Entity Type:Individual
Prefix:DR
First Name:IRYNA
Middle Name:
Last Name:ILYASOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ROUTE 112 STE A
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8055
Mailing Address - Country:US
Mailing Address - Phone:631-743-6840
Mailing Address - Fax:631-743-6841
Practice Address - Street 1:1500 ROUTE 112 STE A
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-8055
Practice Address - Country:US
Practice Address - Phone:631-686-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311503207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine