Provider Demographics
NPI:1942261441
Name:WOLFSON, ILYA (MD)
Entity Type:Individual
Prefix:
First Name:ILYA
Middle Name:
Last Name:WOLFSON
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 1:3353 TRICKUM RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3686
Mailing Address - Country:US
Mailing Address - Phone:770-591-4777
Mailing Address - Fax:770-591-4795
Practice Address - Street 1:3353 TRICKUM RD
Practice Address - Street 2:SUITE 201
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3686
Practice Address - Country:US
Practice Address - Phone:770-591-4777
Practice Address - Fax:770-591-4795
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051860207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA051415364DMedicaid
08BBXDKMedicare ID - Type Unspecified
GA051415364DMedicaid