Provider Demographics
NPI:1548444003
Name:LILLEY, JOHN DAVID (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:LILLEY
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 5183
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5183
Mailing Address - Country:US
Mailing Address - Phone:601-703-4282
Mailing Address - Fax:601-703-4597
Practice Address - Street 1:2500 BLUE RIDGE RD STE 417
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7516
Practice Address - Country:US
Practice Address - Phone:919-787-9097
Practice Address - Fax:601-703-4050
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21601207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05438021Medicaid