Healthcare Provider Details

I. General information

NPI: 1588665111
Provider Name (Legal Business Name): LILLIE MAE WILLIAMS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2005
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24853 ALESSANDRO BLVD #4
MORENO VALLEY CA
92553-6102
US

IV. Provider business mailing address

625 FAIR OAKS AVE STE 270
SOUTH PASADENA CA
91030-5801
US

V. Phone/Fax

Practice location:
  • Phone: 915-571-8518
  • Fax: 877-778-9427
Mailing address:
  • Phone: 626-346-1239
  • Fax: 626-639-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG45814
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberG45814
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: