Healthcare Provider Details

I. General information

NPI: 1104026319
Provider Name (Legal Business Name): ILYA KATZ D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11022 N 28TH DR STE 270
PHOENIX AZ
85029-5639
US

IV. Provider business mailing address

11022 N 28TH DR STE 270
PHOENIX AZ
85029-5639
US

V. Phone/Fax

Practice location:
  • Phone: 623-404-8505
  • Fax: 602-429-8475
Mailing address:
  • Phone: 623-404-8505
  • Fax: 602-429-8475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number005220
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number242526
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number005220
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: