Provider Demographics
NPI:1962627349
Name:LY, KIM-OANH (MD)
Entity Type:Individual
Prefix:DR
First Name:KIM-OANH
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:2505 W HAMMER LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-2839
Practice Address - Country:US
Practice Address - Phone:209-524-1211
Practice Address - Fax:209-491-7584
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA850742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry