Provider Demographics
NPI:1114298957
Name:IDYLLE, LILIANE (DO)
Entity Type:Individual
Prefix:
First Name:LILIANE
Middle Name:
Last Name:IDYLLE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12900 PARK PLAZA DR STE 150
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-9329
Mailing Address - Country:US
Mailing Address - Phone:562-977-4639
Mailing Address - Fax:562-741-4479
Practice Address - Street 1:2444 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-2306
Practice Address - Country:US
Practice Address - Phone:562-333-8288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12060207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA113319OtherSID #113319