Provider Demographics
NPI:1225171713
Name:LY, VAN TUYET (OD)
Entity Type:Individual
Prefix:
First Name:VAN
Middle Name:TUYET
Last Name:LY
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 1:16349 HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-1311
Mailing Address - Country:US
Mailing Address - Phone:714-839-2021
Mailing Address - Fax:714-839-3918
Practice Address - Street 1:16349 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-1311
Practice Address - Country:US
Practice Address - Phone:714-839-2021
Practice Address - Fax:714-839-3918
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10370T152W00000X, 152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0103700Medicaid
CAU76545Medicare UPIN