Provider Demographics
NPI:1972824902
Name:ALISHAYEV, ILYA (DO)
Entity Type:Individual
Prefix:
First Name:ILYA
Middle Name:
Last Name:ALISHAYEV
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 E WT HARRIS BLVD
Practice Address - Street 2:STE 5002
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3485
Practice Address - Country:US
Practice Address - Phone:704-801-7310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-00823207Q00000X
KY03579207Q00000X
VA0116022597207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100252310Medicaid
OH0088842Medicaid
NC1972824902Medicaid
NCNCT443AMedicare PIN
KYK105420Medicare PIN