Provider Demographics
NPI:1417925967
Name:ILIC, VLADIMIR (MD)
Entity Type:Individual
Prefix:DR
First Name:VLADIMIR
Middle Name:
Last Name:ILIC
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-0550
Mailing Address - Fax:239-343-4013
Practice Address - Street 1:13340 METRO PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-4703
Practice Address - Country:US
Practice Address - Phone:239-343-0550
Practice Address - Fax:239-343-0559
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91534207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008656700Medicaid
FLG89939Medicare UPIN
FL008656700Medicaid