Provider Demographics
NPI:1144574732
Name:LAM, LY PHUNG (OD)
Entity Type:Individual
Prefix:
First Name:LY
Middle Name:PHUNG
Last Name:LAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 N EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-3456
Mailing Address - Country:US
Mailing Address - Phone:909-321-4700
Mailing Address - Fax:
Practice Address - Street 1:308 N LA CADENA DR
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-2946
Practice Address - Country:US
Practice Address - Phone:909-321-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-04
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002712152W00000X
MA4952152W00000X
CA33646152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist