Provider Demographics
NPI:1508022021
Name:MAC, LILY (OD)
Entity Type:Individual
Prefix:DR
First Name:LILY
Middle Name:
Last Name:MAC
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 1:1450 TARA HILLS DR
Mailing Address - Street 2:STE D
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2517
Mailing Address - Country:US
Mailing Address - Phone:626-282-2567
Mailing Address - Fax:
Practice Address - Street 1:1450 TARA HILLS DR
Practice Address - Street 2:STE D
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2517
Practice Address - Country:US
Practice Address - Phone:626-282-2567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 13519152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist