Healthcare Provider Details

I. General information

NPI: 1053575886
Provider Name (Legal Business Name): EYONG JOHN LY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 08/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 16TH ST SUITE A454
SANTA MONICA CA
90404-1249
US

IV. Provider business mailing address

1250 16TH ST SUITE A454
SANTA MONICA CA
90404-1249
US

V. Phone/Fax

Practice location:
  • Phone: 310-319-4698
  • Fax: 310-319-4908
Mailing address:
  • Phone: 310-319-4698
  • Fax: 310-319-4908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA113044
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: