=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447513353
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ILYA J. SOBOL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2012
-----------------------------------------------------
Last Update Date | 06/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 CLEARFIELD AVE
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-457-5100
-----------------------------------------------------
Fax | 757-452-3402
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 CLEARFIELD AVE
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462-1815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-457-5100
-----------------------------------------------------
Fax | 757-961-3696
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 0101264201
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 56726
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------