Healthcare Provider Details

I. General information

NPI: 1104920065
Provider Name (Legal Business Name): PIPER P LILLARD D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 11/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 BOSTON TPKE SUITE 2
BOLTON CT
06043-7403
US

IV. Provider business mailing address

54 EASTBROOK HTS APT B
MANSFIELD CENTER CT
06250-1669
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-0649
  • Fax: 860-649-9195
Mailing address:
  • Phone: 860-456-0586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number230057
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: