Provider Demographics
NPI:1497552624
Name:LILLY, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:LILLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10455 STATE ROUTE 139
Mailing Address - Street 2:
Mailing Address - City:MINFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45653-8796
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6020 GROVEPORT RD
Practice Address - Street 2:
Practice Address - City:GROVEPORT
Practice Address - State:OH
Practice Address - Zip Code:43125-1005
Practice Address - Country:US
Practice Address - Phone:614-567-6274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty