Healthcare Provider Details

I. General information

NPI: 1063746485
Provider Name (Legal Business Name): BERNARD JOSEPH ILAGAN MD, MHA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33608 ORTEGA HIGHWAY
SAN JUAN CAPISTRANO CA
92675
US

IV. Provider business mailing address

PO BOX 379
LOMA LINDA CA
92354-0379
US

V. Phone/Fax

Practice location:
  • Phone: 949-728-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME125766
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2023-02684
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberC194982
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207SG0203X
TaxonomyClinical Molecular Genetics Physician
License NumberME125766
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: