Provider Demographics
NPI:1588684724
Name:LY, PETER PHONG (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:PHONG
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 1:14120 ALONDRA BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-5820
Mailing Address - Country:US
Mailing Address - Phone:562-407-2080
Mailing Address - Fax:562-407-2082
Practice Address - Street 1:8016 2ND ST
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3622
Practice Address - Country:US
Practice Address - Phone:562-862-7744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65780207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A657800Medicaid
CA00A657800Medicaid
CAH22743Medicare UPIN
CAWA65780BMedicare PIN
CAA65780AMedicare PIN
CAWA65780DMedicare PIN