Provider Demographics
NPI:1013014794
Name:LY, MICHAEL MINH BA (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MINH BA
Last Name:LY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4868 GOLDEN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92880-9421
Mailing Address - Country:US
Mailing Address - Phone:951-898-3585
Mailing Address - Fax:
Practice Address - Street 1:22450 TOWN CIR
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-7506
Practice Address - Country:US
Practice Address - Phone:951-653-1055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11700T152W00000X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA1700OtherEYEMED