Provider Demographics
NPI:1538279013
Name:ILIC, SERGIO
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:ILIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7033 N FRESNO ST STE 201
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2976
Mailing Address - Country:US
Mailing Address - Phone:559-435-5581
Mailing Address - Fax:559-435-5583
Practice Address - Street 1:7033 N FRESNO ST
Practice Address - Street 2:201
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2976
Practice Address - Country:US
Practice Address - Phone:559-435-5581
Practice Address - Fax:559-435-5583
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31668207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A316680Medicaid
CA00A316680Medicaid
CA00A316680Medicare PIN