Provider Demographics
NPI:1881667087
Name:JUNG, LILY (OD)
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:
Last Name:JUNG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8002 KEW GARDENS RD
Mailing Address - Street 2:SUITE C-108
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-3600
Mailing Address - Country:US
Mailing Address - Phone:718-544-2222
Mailing Address - Fax:
Practice Address - Street 1:8002 KEW GARDENS RD
Practice Address - Street 2:SUITE C-108
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-3600
Practice Address - Country:US
Practice Address - Phone:718-544-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004043-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01194641Medicaid
NY70123Medicare PIN
NY01194641Medicaid