Provider Demographics
NPI:1962552828
Name:LY, MARK LOC BAO (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LOC BAO
Last Name:LY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:7300 N FRESNO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2941
Mailing Address - Country:US
Mailing Address - Phone:559-448-4622
Mailing Address - Fax:
Practice Address - Street 1:7300 N FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2941
Practice Address - Country:US
Practice Address - Phone:559-448-4622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9946T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist