Healthcare Provider Details

I. General information

NPI: 1104895416
Provider Name (Legal Business Name): MOHAMMAD ILYAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 PRUDENTIAL DR STE 405 UFJP PEDIATRIC MULTISPECIALTY
JACKSONVILLE FL
32207-8206
US

IV. Provider business mailing address

PO BOX 44008 UFJP PROVIDER ENROLLMENT
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-633-0920
  • Fax: 904-600-0921
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME75454
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberME75454
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: