Provider Demographics
NPI:1659369445
Name:ILAS, MICHAEL J (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:ILAS
Suffix:
Gender:M
Credentials:DO
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 892577
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92589-2577
Mailing Address - Country:US
Mailing Address - Phone:562-866-1895
Mailing Address - Fax:562-866-5730
Practice Address - Street 1:34859 FREDRICK STREET
Practice Address - Street 2:SUITE 111
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595
Practice Address - Country:US
Practice Address - Phone:562-866-1895
Practice Address - Fax:562-866-5730
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A65602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX65601Medicaid
CA20A6560OtherBLUE SHIELD
CA00AX65601Medicaid
CA20A6560OtherBLUE SHIELD
G17939Medicare UPIN