Provider Demographics
NPI:1003907650
Name:LILLY, MARY SUSAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:SUSAN
Last Name:LILLY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 GOLF MANOR BLVD
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-7852
Mailing Address - Country:US
Mailing Address - Phone:813-716-5150
Mailing Address - Fax:
Practice Address - Street 1:3875 US HIGHWAY 301 S
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578
Practice Address - Country:US
Practice Address - Phone:813-246-3186
Practice Address - Fax:813-542-2246
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3537152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6205704 00Medicaid
FL6205704 00Medicaid