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General NPI Number Information
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NPI Number | 1003907650
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Entity Type | Individual
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Provider Name | MARY SUSAN LILLY O.D.
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Gender | Female
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Dates
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Enumeration Date | 09/27/2006
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Last Update Date | 05/22/2018
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Provider Practice Location Address
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Address Line | 3875 US HIGHWAY 301 S
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City | RIVERVIEW
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State | FL
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Zip | 33578
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Country | US
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Telephone | 813-246-3186
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Fax | 813-542-2246
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Provider Business Mailing Address
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Address Line | 2306 GOLF MANOR BLVD
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City | VALRICO
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State | FL
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Zip | 33596-7852
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Country | US
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Telephone | 813-716-5150
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPC 3537
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License Number State | FL
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