Healthcare Provider Details

I. General information

NPI: 1952566580
Provider Name (Legal Business Name): ANDREW JOSEPH ILLIG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9095 RIO SAN DIEGO DR STE 450
SAN DIEGO CA
92108-1726
US

IV. Provider business mailing address

9095 RIO SAN DIEGO DR STE 410
SAN DIEGO CA
92108-1679
US

V. Phone/Fax

Practice location:
  • Phone: 619-853-8860
  • Fax:
Mailing address:
  • Phone: 858-412-6080
  • Fax: 858-412-6376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number20A13149
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number20A13149
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: