Provider Demographics
NPI:1780732578
Name:LY, SOPHEAP (MD)
Entity type:Individual
Prefix:
First Name:SOPHEAP
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 VALE TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5218
Mailing Address - Country:US
Mailing Address - Phone:760-631-5000
Mailing Address - Fax:760-414-3892
Practice Address - Street 1:134 GRAPEVINE RD
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-4004
Practice Address - Country:US
Practice Address - Phone:607-631-5000
Practice Address - Fax:760-414-3892
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82297207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A822970Medicaid
CA00A822970Medicaid