Provider Demographics
NPI:1619699915
Name:MARK ILYAGU MEDICAL PC
Entity Type:Organization
Organization Name:MARK ILYAGU MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ILYAGU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-716-7107
Mailing Address - Street 1:221 SEA BREEZE AVE APT PH2B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-3454
Mailing Address - Country:US
Mailing Address - Phone:718-790-8718
Mailing Address - Fax:
Practice Address - Street 1:221 SEA BREEZE AVE APT PH2B
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-3454
Practice Address - Country:US
Practice Address - Phone:718-790-8718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-13
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty