Provider Demographics
NPI:1801909056
Name:LY, KEITH K (DO)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:K
Last Name:LY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2993 MILLICENT WY
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107
Mailing Address - Country:US
Mailing Address - Phone:714-757-6651
Mailing Address - Fax:
Practice Address - Street 1:11322 BELLAIRE BLVD STE 117
Practice Address - Street 2:GENERATION MEDICAL CLINIC
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77072
Practice Address - Country:US
Practice Address - Phone:714-757-6651
Practice Address - Fax:281-879-1809
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001670207Q00000X
TXP0068207QA0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1124254Medicaid
H39942Medicare UPIN
WA1124254Medicaid