Basic Information
| Provider Information | |||||||||
| NPI: | 1003907650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LILLY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | SUSAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2306 GOLF MANOR BLVD | ||||||||
| Address2: | |||||||||
| City: | VALRICO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335967852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137165150 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3875 US HIGHWAY 301 S | ||||||||
| Address2: | |||||||||
| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132463186 | ||||||||
| FaxNumber: | 8135422246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 05/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC 3537 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 6205704 00 | 05 | FL | MEDICAID |