Provider Demographics
NPI:1578828265
Name:LY, DAVID (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:14405 W COLFAX AVE
Mailing Address - Street 2:#310
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80401-3247
Mailing Address - Country:US
Mailing Address - Phone:303-215-0376
Mailing Address - Fax:303-302-6906
Practice Address - Street 1:7611 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-5439
Practice Address - Country:US
Practice Address - Phone:623-873-1098
Practice Address - Fax:623-849-9459
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1861152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist