Provider Demographics
NPI:1740231927
Name:LILLIE, MICHAEL JOHN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:LILLIE
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:PO BOX 1628
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92856-0628
Mailing Address - Country:US
Mailing Address - Phone:714-560-1580
Mailing Address - Fax:714-560-1585
Practice Address - Street 1:101 E VALENCIA MESA DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3809
Practice Address - Country:US
Practice Address - Phone:714-871-3280
Practice Address - Fax:714-447-6490
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63391207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G633910Medicaid
CAWG63391BMedicare ID - Type Unspecified
E84955Medicare UPIN