Provider Demographics
NPI:1750606448
Name:CHANG, LILLY
Entity type:Individual
Prefix:
First Name:LILLY
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 DOCKVIEW WAY APT 1421
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-6734
Mailing Address - Country:US
Mailing Address - Phone:813-849-3147
Mailing Address - Fax:
Practice Address - Street 1:501 6TH AVE S
Practice Address - Street 2:DEPARTMENT 6590170301
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4634
Practice Address - Country:US
Practice Address - Phone:352-273-8985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME117162208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics