Provider Demographics
NPI:1417120601
Name:ILYAS, HUMZA (MD)
Entity Type:Individual
Prefix:DR
First Name:HUMZA
Middle Name:
Last Name:ILYAS
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 1:3379 PEACHTREE RD NE STE 500
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-1418
Mailing Address - Country:US
Mailing Address - Phone:404-591-4313
Mailing Address - Fax:678-420-7099
Practice Address - Street 1:3379 PEACHTREE RD NE STE 500
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30326-1418
Practice Address - Country:US
Practice Address - Phone:404-591-4313
Practice Address - Fax:678-420-7099
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25907207N00000X
VA010101256173207ND0101X
GAGA64830207ND0101X
GA064830207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAQ46849AMedicare PIN
WVWV4593AMedicare PIN
GA202I079364Medicare PIN