Provider Demographics
NPI:1386836591
Name:LY, VAN B (OD)
Entity Type:Individual
Prefix:DR
First Name:VAN
Middle Name:B
Last Name:LY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:VAN
Other - Middle Name:B
Other - Last Name:LY-REYES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:319 7TH AVE SE
Mailing Address - Street 2:SUITE #101
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-1325
Mailing Address - Country:US
Mailing Address - Phone:360-357-2544
Mailing Address - Fax:360-786-8734
Practice Address - Street 1:319 7TH AVE SE
Practice Address - Street 2:SUITE #101
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-1325
Practice Address - Country:US
Practice Address - Phone:360-357-2544
Practice Address - Fax:360-786-8734
Is Sole Proprietor?:No
Enumeration Date:2007-08-11
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3211ATI152W00000X
WA60013431152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist