Provider Demographics
NPI:1609836998
Name:ILLICK, CHRISTOPHER DUNBAR (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:DUNBAR
Last Name:ILLICK
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 1:687 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3612
Mailing Address - Country:US
Mailing Address - Phone:203-481-7050
Mailing Address - Fax:203-481-6788
Practice Address - Street 1:1224 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3778
Practice Address - Country:US
Practice Address - Phone:203-481-0315
Practice Address - Fax:203-481-6788
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043283207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001432830Medicaid
H35324Medicare UPIN
CT100000403Medicare PIN