Healthcare Provider Details

I. General information

NPI: 1508036591
Provider Name (Legal Business Name): PETER LY MD MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10921 CHERRY ST STE 200
LOS ALAMITOS CA
90720-2473
US

IV. Provider business mailing address

PO BOX 4259
CERRITOS CA
90703-4259
US

V. Phone/Fax

Practice location:
  • Phone: 562-407-2080
  • Fax: 562-407-2082
Mailing address:
  • Phone: 562-407-2080
  • Fax: 562-407-2082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA65780
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA65780
License Number StateCA

VIII. Authorized Official

Name: PETER LY
Title or Position: PRESIDENT
Credential: MD
Phone: 562-407-2080