Provider Demographics
NPI:1316039373
Name:ILYIN, ALEX (OD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:ILYIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 853
Mailing Address - Street 2:
Mailing Address - City:EVERSON
Mailing Address - State:WA
Mailing Address - Zip Code:98247-0853
Mailing Address - Country:US
Mailing Address - Phone:360-966-0445
Mailing Address - Fax:
Practice Address - Street 1:205 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:EVERSON
Practice Address - State:WA
Practice Address - Zip Code:98247
Practice Address - Country:US
Practice Address - Phone:360-966-0445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003776152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2029098Medicaid
WAAB33781Medicare ID - Type UnspecifiedMEDICARE NUMBER
WA2029098Medicaid