Healthcare Provider Details

I. General information

NPI: 1306924915
Provider Name (Legal Business Name): JAMES ILKO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1687 WOODLANE DRIVE SUITE 102
WOODBURY MN
55125-3045
US

IV. Provider business mailing address

821 REDWOOD DR
FAIRMONT MN
56031-3025
US

V. Phone/Fax

Practice location:
  • Phone: 651-209-6685
  • Fax: 651-209-1680
Mailing address:
  • Phone: 612-802-5253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35700
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: