Provider Demographics
NPI:1164886081
Name:ILIAS, MD (MD)
Entity Type:Individual
Prefix:
First Name:MD
Middle Name:
Last Name:ILIAS
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 1:3824 PRESCOTT ST
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-3116
Mailing Address - Country:US
Mailing Address - Phone:347-420-6388
Mailing Address - Fax:
Practice Address - Street 1:178 OCEAN PKWY APT E9
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-2454
Practice Address - Country:US
Practice Address - Phone:347-420-6388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-06
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019616363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant