Provider Demographics
NPI:1184280497
Name:ILUSTRISIMO, THOMAS LEMUEL (DO)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LEMUEL
Last Name:ILUSTRISIMO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10624 S EASTERN AVE # A-955
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-2982
Mailing Address - Country:US
Mailing Address - Phone:702-407-7700
Mailing Address - Fax:027-407-7016
Practice Address - Street 1:10624 S EASTERN AVE # A-955
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-2982
Practice Address - Country:US
Practice Address - Phone:702-407-7700
Practice Address - Fax:027-407-7016
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSL1459207R00000X
NVDO3016207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine