Provider Demographics
NPI:1972966265
Name:ILYAS, GHULAM (MD)
Entity Type:Individual
Prefix:
First Name:GHULAM
Middle Name:
Last Name:ILYAS
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 1:6325 HOSPITAL PKWY
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-5775
Mailing Address - Country:US
Mailing Address - Phone:678-474-7000
Mailing Address - Fax:
Practice Address - Street 1:6325 HOSPITAL PKWY
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-5775
Practice Address - Country:US
Practice Address - Phone:516-312-9848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2021-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036151147207ZP0102X
390200000X
GA88046207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program