Provider Demographics
NPI:1720026842
Name:LY, TAM VAN (DC)
Entity Type:Individual
Prefix:DR
First Name:TAM
Middle Name:VAN
Last Name:LY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 HAMILTON AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95130-1748
Mailing Address - Country:US
Mailing Address - Phone:510-303-0807
Mailing Address - Fax:408-550-1974
Practice Address - Street 1:4950 HAMILTON AVE STE 109
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95130-1748
Practice Address - Country:US
Practice Address - Phone:408-256-3865
Practice Address - Fax:408-550-1974
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2019-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 29804111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV10179Medicare UPIN