Provider Demographics
NPI:1871912907
Name:PHAN, LILY (MD)
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:572 WESTMINSTER AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-2207
Mailing Address - Country:US
Mailing Address - Phone:480-332-9734
Mailing Address - Fax:
Practice Address - Street 1:225 WILLIAMSON ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202
Practice Address - Country:US
Practice Address - Phone:908-994-5204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA10316400207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program