MEDICARE: ILYA WOLFSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	051860	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942261441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILYA WOLFSON MD

Provider Business Mailing Address
First Line	:	3380 TRICKUM RD BLDG 1000-102
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30188-3690
Country	:	US
Telephone Number	:	770-591-4777
Fax Number	:	770-591-4795

Provider Business Practice Location Address
First Line	:	3380 TRICKUM RD BLDG 1000-102
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30188-3690
Country	:	US
Telephone Number	:	770-591-4777
Fax Number	:	770-591-4795

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2006
Last Update Date	:	01/23/2025

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