Provider Demographics
NPI:1083665830
Name:LILLICH, DAVID W (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:W
Last Name:LILLICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1155 N MAYFAIR RD
Mailing Address - Street 2:PLANK ROAD CLINIC
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3421
Mailing Address - Country:US
Mailing Address - Phone:414-955-5990
Mailing Address - Fax:414-955-6282
Practice Address - Street 1:1155 N MAYFAIR RD
Practice Address - Street 2:PLANK ROAD CLINIC
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3421
Practice Address - Country:US
Practice Address - Phone:414-955-5990
Practice Address - Fax:414-955-6282
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI22717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
002000124SOtherHUMANA
WI1083665830Medicaid
WI30286700Medicaid
WI1083665830Medicaid
B54586Medicare UPIN