Provider Demographics
NPI:1760706709
Name:LY, BEN VIET (M D)
Entity Type:Individual
Prefix:DR
First Name:BEN
Middle Name:VIET
Last Name:LY
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 NW 22ND AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2969
Mailing Address - Country:US
Mailing Address - Phone:503-413-8988
Mailing Address - Fax:
Practice Address - Street 1:1130 NW 22ND AVE STE 220
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2969
Practice Address - Country:US
Practice Address - Phone:503-413-8988
Practice Address - Fax:503-413-5629
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-19
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD162402207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine