Provider Demographics
NPI:1558456517
Name:REYTER, ILYA (MD)
Entity Type:Individual
Prefix:
First Name:ILYA
Middle Name:
Last Name:REYTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ILYA
Other - Middle Name:
Other - Last Name:REYTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4836 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-2101
Mailing Address - Country:US
Mailing Address - Phone:818-907-7546
Mailing Address - Fax:818-907-9506
Practice Address - Street 1:4836 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-2101
Practice Address - Country:US
Practice Address - Phone:818-907-7546
Practice Address - Fax:818-907-9506
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79982207N00000X, 207NS0135X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI63792Medicare UPIN