Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0129X | Vascular Surgeon | ME111162 | FL |
NPI | 1023053303 |
---|---|
Provider Name | Dr. Karl Armistead Illig |
First Address | Orlando, FL 32891-7770 |
Second Address | Tampa, FL 33606-3603 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/06/2006 |
Last Update Date | 01/05/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
004120700 | (05) | FL |
14H55 | BLUE CROSS BLUE SHIELD (01) | FL |
G44978 | (02) |