Provider Demographics
NPI:1417933961
Name:ILLESCAS, FERNANDO F (MD)
Entity type:Individual
Prefix:
First Name:FERNANDO
Middle Name:F
Last Name:ILLESCAS
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 1:701 COTTAGE GROVE RD STE E110
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3085
Mailing Address - Country:US
Mailing Address - Phone:860-519-0620
Mailing Address - Fax:860-904-2463
Practice Address - Street 1:701 COTTAGE GROVE RD STE E110
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3085
Practice Address - Country:US
Practice Address - Phone:860-265-2529
Practice Address - Fax:860-463-9562
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0313712085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001313717Medicaid
CT010031371CT01OtherANTHEM BC/BS
CT1417933961Medicaid
CTA2516306OtherOXFORD