Provider Demographics
NPI:1649290701
Name:LY, ETHAN DIEU (OD)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:DIEU
Last Name:LY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 MAYFIELD DR
Mailing Address - Street 2:SUITE D2
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-7203
Mailing Address - Country:US
Mailing Address - Phone:615-771-1020
Mailing Address - Fax:
Practice Address - Street 1:330 MAYFIELD DR
Practice Address - Street 2:SUITE D2
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-7203
Practice Address - Country:US
Practice Address - Phone:615-771-1020
Practice Address - Fax:615-771-9263
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2251152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2694372OtherCIGNA HEALTHCARE
TN4098341OtherBCBS
TN2507272OtherUNITED HEALTHCARE
TN3946543Medicare ID - Type UnspecifiedPROVIDER #