1588665111 NPI number — LILLIE MAE WILLIAMS M.D.

Table of content: LILLIE MAE WILLIAMS M.D. (NPI 1588665111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588665111 NPI number — LILLIE MAE WILLIAMS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMS
Provider First Name:
LILLIE
Provider Middle Name:
MAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588665111
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 FAIR OAKS AVE STE 270
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91030-5801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-346-1239
Provider Business Mailing Address Fax Number:
626-639-3005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24853 ALESSANDRO BLVD
Provider Second Line Business Practice Location Address:
#4
Provider Business Practice Location Address City Name:
MORENO VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92553-6102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-571-8518
Provider Business Practice Location Address Fax Number:
877-778-9427
Provider Enumeration Date:
08/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080P0006X , with the licence number:  G45814 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: G45814 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G458140 . This is a "MEDI CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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