Provider Demographics
NPI:1477879864
Name:LY, DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
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 1:20800 HARVARD RD FL 2
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-7250
Mailing Address - Country:US
Mailing Address - Phone:216-358-2156
Mailing Address - Fax:216-201-7880
Practice Address - Street 1:6847 N CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3929
Practice Address - Country:US
Practice Address - Phone:330-235-7081
Practice Address - Fax:216-201-6387
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ510212085R0001X
390200000X
OH35.1292742085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP01536506OtherRAILROAD MEDICARE
AZQZZ000000061638OtherMERCY CARE
AZ3495287OtherCIGNA
AZ041529Medicaid
AZ7140968OtherAETNA