Provider Demographics
NPI:1447010137
Name:LY, NGOC VAN DAI (MD)
Entity type:Individual
Prefix:
First Name:NGOC VAN DAI
Middle Name:
Last Name:LY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28062 BAXTER RD OFC
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-1401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28062 BAXTER RD
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-1401
Practice Address - Country:US
Practice Address - Phone:951-290-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-20
Last Update Date:2025-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16931390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program