MEDICARE: LILY LI OD

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	152W00000X	Optometrist	046.010733	IL
2	152W00000X	Optometrist	TUV008032-1	NY

General Provider Information

NPI Number	:	1649611831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILY LI OD

Provider Business Mailing Address
First Line	:	1456 S PEORIA ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-2208
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2343B S WENTWORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-2013
Country	:	US
Telephone Number	:	312-225-5829
Fax Number	:

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

Provider Enumeration Date	:	07/16/2013
Last Update Date	:	03/17/2018

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Directions to “ LILY LI OD” Practice Location

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