Provider Demographics
NPI:1124097183
Name:WILKERSON, ILLYA L (MD)
Entity type:Individual
Prefix:
First Name:ILLYA
Middle Name:L
Last Name:WILKERSON
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 1:4950 W SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-5822
Mailing Address - Country:US
Mailing Address - Phone:323-783-7582
Mailing Address - Fax:
Practice Address - Street 1:4950 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5822
Practice Address - Country:US
Practice Address - Phone:323-783-7582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900388207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89126UMMedicaid
NCP00011666OtherRAILROAD MEDICARE
NC126UMOtherBCBS
NC126UMOtherBCBS
NCP00011666OtherRAILROAD MEDICARE