Healthcare Provider Details

I. General information

NPI: 1427317460
Provider Name (Legal Business Name): ILYA YAKHNENKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2012
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36485 INLAND VALLEY DR
WILDOMAR CA
92595-9681
US

IV. Provider business mailing address

3208 CORTE PACIFICA
CARLSBAD CA
92009-6096
US

V. Phone/Fax

Practice location:
  • Phone: 951-677-1111
  • Fax:
Mailing address:
  • Phone: 442-325-1537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA132053
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: