Provider Demographics
NPI:1013302322
Name:ILMER, SOFYA
Entity Type:Individual
Prefix:DR
First Name:SOFYA
Middle Name:
Last Name:ILMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7050 AIR DEPOT BLVD
Mailing Address - Street 2:BLDG 1094
Mailing Address - City:TINKER AFB
Mailing Address - State:OK
Mailing Address - Zip Code:73145-8716
Mailing Address - Country:US
Mailing Address - Phone:405-582-6610
Mailing Address - Fax:
Practice Address - Street 1:72D MEDICAL GROUP, 7050 AIR DEPOT BLVD
Practice Address - Street 2:BLVD 1094
Practice Address - City:TINKER AFB
Practice Address - State:OK
Practice Address - Zip Code:73145-8716
Practice Address - Country:US
Practice Address - Phone:405-582-6610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY285311208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice