Provider Demographics
NPI:1275517062
Name:KHAMISHON, ILYA (MD)
Entity Type:Individual
Prefix:DR
First Name:ILYA
Middle Name:
Last Name:KHAMISHON
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 1:4304 ESPLANADE CIR
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-7385
Mailing Address - Country:US
Mailing Address - Phone:916-217-4592
Mailing Address - Fax:
Practice Address - Street 1:4304 ESPLANADE CIR.
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630
Practice Address - Country:US
Practice Address - Phone:916-217-4592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA054344207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A543440Medicaid
CA00A543440Medicaid
00A543440Medicare PIN