Provider Demographics
NPI:1952306201
Name:LILLIE, DAVID B (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:B
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 1:400 INTERNATIONAL DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5771
Mailing Address - Country:US
Mailing Address - Phone:716-873-3828
Mailing Address - Fax:716-873-5463
Practice Address - Street 1:3800 DELAWARE AVE
Practice Address - Street 2:STE 104
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1094
Practice Address - Country:US
Practice Address - Phone:716-873-3828
Practice Address - Fax:716-873-5463
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY145776-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1900426OtherIHA
NY00010104801OtherUNIVERA
NY00607167Medicaid
NY040426001716OtherFIDELIS
NYC57911Medicare UPIN