Healthcare Provider Details

I. General information

NPI: 1023344991
Provider Name (Legal Business Name): MICHAEL L ILLINGWORTH, MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2009
Last Update Date: 10/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

681 MEDICAL CENTER DR W STE 101
CLOVIS CA
93611-6803
US

IV. Provider business mailing address

681 MEDICAL CENTER DR W STE 101
CLOVIS CA
93611-6803
US

V. Phone/Fax

Practice location:
  • Phone: 559-323-9300
  • Fax:
Mailing address:
  • Phone: 559-323-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL L ILLINGWORTH
Title or Position: OWNER
Credential: MD
Phone: 559-323-9300