Provider Demographics
NPI:1447487863
Name:LY, NAM VIET (OD)
Entity type:Individual
Prefix:DR
First Name:NAM
Middle Name:VIET
Last Name:LY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:VIETNAM
Other - Middle Name:
Other - Last Name:LY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:2169 SEAVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-1236
Mailing Address - Country:US
Mailing Address - Phone:323-842-5155
Mailing Address - Fax:
Practice Address - Street 1:9333 ROSECRANS AVE
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-2141
Practice Address - Country:US
Practice Address - Phone:323-842-5155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-11
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA13855TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program