Provider Demographics
NPI:1588665111
Name:WILLIAMS, LILLIE MAE (MD)
Entity Type:Individual
Prefix:
First Name:LILLIE
Middle Name:MAE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 FAIR OAKS AVE STE 270
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-5801
Mailing Address - Country:US
Mailing Address - Phone:626-346-1239
Mailing Address - Fax:626-639-3005
Practice Address - Street 1:24853 ALESSANDRO BLVD
Practice Address - Street 2:#4
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-6102
Practice Address - Country:US
Practice Address - Phone:915-571-8518
Practice Address - Fax:877-778-9427
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG458142080P0006X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G458140OtherMEDI CAL
CAF52362Medicare UPIN