Provider Demographics
NPI:1750807509
Name:ILAGAN, RICHARD (PTA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:ILAGAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11535 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-7373
Mailing Address - Country:US
Mailing Address - Phone:352-592-0010
Mailing Address - Fax:352-592-0011
Practice Address - Street 1:11535 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-7373
Practice Address - Country:US
Practice Address - Phone:352-592-0010
Practice Address - Fax:352-592-0011
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA25638208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA25638OtherPT LICENSE