Provider Demographics
NPI:1700889128
Name:LY, UYEN T (MD)
Entity Type:Individual
Prefix:DR
First Name:UYEN
Middle Name:T
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:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:GUERNEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95446-1449
Mailing Address - Country:US
Mailing Address - Phone:707-874-2444
Mailing Address - Fax:707-874-1664
Practice Address - Street 1:3802 MAIN STREET
Practice Address - Street 2:
Practice Address - City:OCCIDENTAL
Practice Address - State:CA
Practice Address - Zip Code:95465
Practice Address - Country:US
Practice Address - Phone:707-874-2444
Practice Address - Fax:707-874-1664
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC03899GMedicaid
CAZZZ23666ZOtherBLUE SHIELD PIN
CAZZZ23666ZOtherBLUE SHIELD PIN
CAZZZ21461ZMedicare ID - Type UnspecifiedMEDICARE PART B
CAI07353Medicare UPIN