Provider Demographics
NPI:1437189941
Name:LILLIE, ROBERT CHARLES (DPM)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:CHARLES
Last Name:LILLIE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 LEONARDVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BELFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07718-1042
Mailing Address - Country:US
Mailing Address - Phone:732-787-4747
Mailing Address - Fax:732-495-9123
Practice Address - Street 1:55 LEONARDVILLE RD
Practice Address - Street 2:
Practice Address - City:BELFORD
Practice Address - State:NJ
Practice Address - Zip Code:07718-1042
Practice Address - Country:US
Practice Address - Phone:732-787-4747
Practice Address - Fax:732-495-9123
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD01309213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4696204Medicaid
6152140002Medicare NSC
NJLI084075Medicare ID - Type Unspecified
U23546Medicare UPIN