Provider Demographics
NPI:1811956857
Name:LY, PHUOC THI (OD)
Entity type:Individual
Prefix:DR
First Name:PHUOC
Middle Name:THI
Last Name:LY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2921 ERIE BLVD EAST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224
Mailing Address - Country:US
Mailing Address - Phone:315-445-7465
Mailing Address - Fax:315-445-7675
Practice Address - Street 1:2590 RIDGE RD W
Practice Address - Street 2:EMPIRE VISION CENTERS
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-3041
Practice Address - Country:US
Practice Address - Phone:585-227-7150
Practice Address - Fax:585-227-1999
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0069141152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V07068Medicare UPIN
NYRA8436Medicare PIN
NYRA8433Medicare ID - Type Unspecified
NYRA8434Medicare PIN
NYRA8435Medicare PIN