Provider Demographics
NPI:1376761767
Name:LY, CALVIN C (DO)
Entity Type:Individual
Prefix:DR
First Name:CALVIN
Middle Name:C
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 1:250 POINT LOBOS AVE APT 603
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94121-1402
Mailing Address - Country:US
Mailing Address - Phone:714-883-8261
Mailing Address - Fax:
Practice Address - Street 1:600 ALFRED NOBEL DR STE A
Practice Address - Street 2:
Practice Address - City:HERCULES
Practice Address - State:CA
Practice Address - Zip Code:94547-1834
Practice Address - Country:US
Practice Address - Phone:510-984-1103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58001776207P00000X
CA20A 10209207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine