Provider Demographics
NPI:1124509252
Name:LY, RICHARD (OD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
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 1:600 S BEACH BLVD APT 6
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3150
Mailing Address - Country:US
Mailing Address - Phone:408-876-0145
Mailing Address - Fax:
Practice Address - Street 1:17801 PIONEER BLVD
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-3962
Practice Address - Country:US
Practice Address - Phone:562-467-0813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34078TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist