Provider Demographics
NPI:1376557918
Name:LILLY, DALE BLAKE (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:BLAKE
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 1:2823 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702-1423
Mailing Address - Country:US
Mailing Address - Phone:304-523-3937
Mailing Address - Fax:304-523-3945
Practice Address - Street 1:2823 3RD AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1423
Practice Address - Country:US
Practice Address - Phone:304-523-3937
Practice Address - Fax:304-523-3945
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17041207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV17041OtherWV STATE
WV0096101000Medicaid
OH0219534Medicaid
G22261Medicare UPIN
WV0096101000Medicaid