Provider Demographics
NPI:1114248218
Name:LY, ANGE MONG (MD)
Entity Type:Individual
Prefix:
First Name:ANGE MONG
Middle Name:
Last Name:LY
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 1:24800 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3378
Mailing Address - Country:US
Mailing Address - Phone:503-674-1122
Mailing Address - Fax:
Practice Address - Street 1:24800 SE STARK ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3378
Practice Address - Country:US
Practice Address - Phone:503-674-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-13
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD160078207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine