Provider Demographics
NPI:1669408126
Name:LILLIS, FREDERICK P (MD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:P
Last Name:LILLIS
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 1:224D CORNWALL ST NW
Mailing Address - Street 2:SUITE 302
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2700
Mailing Address - Country:US
Mailing Address - Phone:703-737-7622
Mailing Address - Fax:703-737-7943
Practice Address - Street 1:224D CORNWALL ST NW
Practice Address - Street 2:SUITE 302
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-2700
Practice Address - Country:US
Practice Address - Phone:703-737-7622
Practice Address - Fax:703-737-7943
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101022634207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA061845OtherANTHEM BLUE CROSS
B09831Medicare UPIN
VA112888502Medicare ID - Type Unspecified