Healthcare Provider Details

I. General information

NPI: 1114248218
Provider Name (Legal Business Name): ANGE MONG LY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2010
Last Update Date: 07/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24800 SE STARK ST
GRESHAM OR
97030-3378
US

IV. Provider business mailing address

24800 SE STARK ST
GRESHAM OR
97030-3378
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-1122
  • Fax:
Mailing address:
  • Phone: 503-674-1122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD160078
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: