Provider Demographics
NPI:1932294287
Name:LY, ANDREW H (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:H
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 1:401 THE MEWS
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-3254
Mailing Address - Country:US
Mailing Address - Phone:203-720-2395
Mailing Address - Fax:203-723-7849
Practice Address - Street 1:1060 NEW HAVEN RD
Practice Address - Street 2:
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-4731
Practice Address - Country:US
Practice Address - Phone:203-720-2395
Practice Address - Fax:203-723-7849
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT002624152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU96972Medicare UPIN