Provider Demographics
NPI:1538101670
Name:LY, LUONG T (MD)
Entity Type:Individual
Prefix:
First Name:LUONG
Middle Name:T
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:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92546-0788
Mailing Address - Country:US
Mailing Address - Phone:951-929-6260
Mailing Address - Fax:951-765-2855
Practice Address - Street 1:99 S RAYMOND AVE # 610
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2046
Practice Address - Country:US
Practice Address - Phone:626-890-7973
Practice Address - Fax:626-890-7973
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86007207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0059670Medicaid
CAA86007OtherCA STATE LICENSE #
CAI17692Medicare UPIN
CA203385368OtherFEDERAL EIN
CABL8763648OtherDEA CERTIFICATE #
CAW13072Medicare ID - Type UnspecifiedMEDICARE GRP PROV #
CA00A850070Medicaid
CAWA860070Medicare ID - Type UnspecifiedMEDICARE INDIV PROV #