Provider Demographics
NPI:1558625293
Name:LILLVIS, JOHN HUNT (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HUNT
Last Name:LILLVIS
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 1:1176 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-2102
Mailing Address - Country:US
Mailing Address - Phone:716-881-7917
Mailing Address - Fax:
Practice Address - Street 1:1176 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209
Practice Address - Country:US
Practice Address - Phone:716-881-7917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY289495207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04876748Medicaid
NY04876748Medicaid