Healthcare Provider Details

I. General information

NPI: 1972966265
Provider Name (Legal Business Name): GHULAM ILYAS M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 06/27/2021
Certification Date: 06/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6325 HOSPITAL PKWY
JOHNS CREEK GA
30097-5775
US

IV. Provider business mailing address

6325 HOSPITAL PKWY
JOHNS CREEK GA
30097-5775
US

V. Phone/Fax

Practice location:
  • Phone: 516-312-9848
  • Fax:
Mailing address:
  • Phone: 678-474-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036151147
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number88046
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: