Provider Demographics
NPI:1932287620
Name:MICHAEL J ILAS DO A CALIFORNIA PROFESSIONAL MEDICAL CORP
Entity Type:Organization
Organization Name:MICHAEL J ILAS DO A CALIFORNIA PROFESSIONAL MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:ILAS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:562-866-1895
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A65602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A6560OtherBLUE SHIELD
CA00AX65601Medicaid
G17939Medicare UPIN
CA20A6560OtherBLUE SHIELD
CA00AX65601Medicaid