Provider Demographics
NPI:1982619318
Name:ILARDA, ISABELLA (MD)
Entity Type:Individual
Prefix:
First Name:ISABELLA
Middle Name:
Last Name:ILARDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78-12 METROPOLITAN AVE
Mailing Address - Street 2:NEW AGE DERMATOLOGY
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-2900
Mailing Address - Country:US
Mailing Address - Phone:718-416-4600
Mailing Address - Fax:718-416-4603
Practice Address - Street 1:78-12 METROPOLITAN AVE
Practice Address - Street 2:NEW AGE DERMATOLOGY
Practice Address - City:MIDDLE VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11379-2900
Practice Address - Country:US
Practice Address - Phone:718-416-4600
Practice Address - Fax:718-416-4603
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206401207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06U501Medicare UPIN
NY08155Medicare PIN
06U5085661Medicare PIN