Provider Demographics
NPI:1477536423
Name:MARK -MAASDAM, LILY (OD)
Entity Type:Individual
Prefix:MRS
First Name:LILY
Middle Name:
Last Name:MARK -MAASDAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:50138-1712
Mailing Address - Country:US
Mailing Address - Phone:641-842-3616
Mailing Address - Fax:641-842-5453
Practice Address - Street 1:100 S 5TH ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:IA
Practice Address - Zip Code:50138-1712
Practice Address - Country:US
Practice Address - Phone:641-842-3616
Practice Address - Fax:641-842-5453
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02111152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1186106Medicaid
IA48881OtherBLUE CROSS
IAU74394Medicare UPIN
IA1186106Medicaid