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General NPI Number Information
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NPI Number | 1427175983
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Entity Type | Organization
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Legal Business Name | SERGIO ILIC, M.D., PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 03/22/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 264 CLOVIS AVE SUITE 207
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City | CLOVIS
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State | CA
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Zip | 93612-1115
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Country | US
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Telephone | 559-324-6504
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Fax |
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Provider Business Mailing Address
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Address Line | 4910 E CLINTON WAY SUITE 101
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City | FRESNO
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State | CA
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Zip | 93727-1560
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Country | US
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Telephone | 559-453-5203
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Fax | 559-453-3321
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SERGIO ILIC
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Credential | M.D.
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Telephone | 559-324-6504
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | A31668
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License Number State | CA
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