Healthcare Provider Details

I. General information

NPI: 1427175983
Provider Name (Legal Business Name): SERGIO ILIC, M.D., PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 CLOVIS AVE SUITE 207
CLOVIS CA
93612-1115
US

IV. Provider business mailing address

4910 E CLINTON WAY SUITE 101
FRESNO CA
93727-1560
US

V. Phone/Fax

Practice location:
  • Phone: 559-324-6504
  • Fax:
Mailing address:
  • Phone: 559-453-5203
  • Fax: 559-453-3321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA31668
License Number StateCA

VIII. Authorized Official

Name: DR. SERGIO ILIC
Title or Position: PRESIDENT
Credential: M.D.
Phone: 559-324-6504