Provider Demographics
NPI:1154307932
Name:LILLY, THEODORE J (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:J
Last Name:LILLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 S. W. WILSHIRE BLVD.
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-5330
Mailing Address - Country:US
Mailing Address - Phone:817-447-1208
Mailing Address - Fax:817-447-1106
Practice Address - Street 1:434 S.W. WILSHIRE
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-5330
Practice Address - Country:US
Practice Address - Phone:817-447-1208
Practice Address - Fax:817-447-1106
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9146207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000N84V4Medicaid
110088148OtherMEDICARE RR
TX89072SOtherBCBS
N84VMedicare PIN
TX00N84VMedicare PIN
TX89072SOtherBCBS