Basic Information
| Provider Information | |||||||||
| NPI: | 1043226889 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHRISTY | ||||||||
| FirstName: | ILIA | ||||||||
| MiddleName: | J.L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WAKEHAM | ||||||||
| OtherFirstName: | ILIA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4011 FANUEL ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921095207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267557409 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3811 VALLEY CENTRE DR | ||||||||
| Address2: | S99 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921303318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587643000 | ||||||||
| FaxNumber: | 8587643025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 11/02/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A85980 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | A85980 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.