Provider Demographics
NPI:1861658650
Name:ILYADIS, LATIA HOLDER (DO)
Entity Type:Individual
Prefix:DR
First Name:LATIA
Middle Name:HOLDER
Last Name:ILYADIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:LATIA
Other - Middle Name:
Other - Last Name:HOLDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 643608
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32964-3608
Mailing Address - Country:US
Mailing Address - Phone:772-205-6361
Mailing Address - Fax:772-410-5477
Practice Address - Street 1:9301 HIGHWAY A1A STE 202
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32963-5602
Practice Address - Country:US
Practice Address - Phone:772-205-6361
Practice Address - Fax:772-410-5477
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12261207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009243400Medicaid