Basic Information
| Provider Information | |||||||||
| NPI: | 1265512982 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LY | ||||||||
| FirstName: | PHUONG | ||||||||
| MiddleName: | CHI | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 26800 CROWN VALLEY PKWY STE 150 | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926918018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492762111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 26800 CROWN VALLEY PKWY STE 150 | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926918018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492762111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | C8448 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | A53516 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 130542001 | 05 | AR | MEDICAID |