Healthcare Provider Details

I. General information

NPI: 1356785364
Provider Name (Legal Business Name): ILYA ZOLOTNIK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. ILYA KVASHA

II. Dates (important events)

Enumeration Date: 04/21/2013
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 BENTON ST
LOMA LINDA CA
92357-2804
US

IV. Provider business mailing address

11201 BENTON ST DEPT OF
LOMA LINDA CA
92357-2804
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone: 909-825-7084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA132508
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberA132508
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: