Provider Demographics
NPI:1124032917
Name:LY, DUONG THAI (MD)
Entity Type:Individual
Prefix:
First Name:DUONG
Middle Name:THAI
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:PO BOX 62556
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2556
Mailing Address - Country:US
Mailing Address - Phone:302-709-4528
Mailing Address - Fax:302-733-0854
Practice Address - Street 1:1006 TAVERN RD
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2864
Practice Address - Country:US
Practice Address - Phone:304-267-5141
Practice Address - Fax:304-267-5140
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD69151207L00000X
WV24121207L00000X
VA0101246849207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD165323ZAXMedicare PIN
WV4302011Medicare PIN