MEDICARE: ILLYA L WILKERSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	9900388	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00011666	OTHER	NC	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	126UM	OTHER	NC	BCBS

General Provider Information

NPI Number	:	1124097183
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILLYA L WILKERSON MD

Provider Business Mailing Address
First Line	:	4950 W SUNSET BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-5822
Country	:	US
Telephone Number	:	323-783-7582
Fax Number	:

Provider Business Practice Location Address
First Line	:	4950 W SUNSET BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-5822
Country	:	US
Telephone Number	:	323-783-7582
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	11/29/2021

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