Provider Demographics
NPI:1891007787
Name:LY, THOMAS C (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:C
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 1:13236 N 7TH ST
Mailing Address - Street 2:STE 4- 255
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-5343
Mailing Address - Country:US
Mailing Address - Phone:928-854-0002
Mailing Address - Fax:928-453-0885
Practice Address - Street 1:101 CIVIC CENTER LN
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5607
Practice Address - Country:US
Practice Address - Phone:928-854-0002
Practice Address - Fax:928-453-0885
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ45537207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ666099Medicaid
AZZ149928Medicare PIN