Provider Demographics
NPI:1154453777
Name:HILSMAN, IREY DOLORES
Entity Type:Individual
Prefix:MS
First Name:IREY
Middle Name:DOLORES
Last Name:HILSMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 W 121ST ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-3909
Mailing Address - Country:US
Mailing Address - Phone:323-750-0640
Mailing Address - Fax:323-777-6446
Practice Address - Street 1:2220 W MANCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90305-2514
Practice Address - Country:US
Practice Address - Phone:323-750-0640
Practice Address - Fax:323-777-6446
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ30895ZMedicaid
CAX058540Medicare PIN