Provider Demographics
NPI:1053977579
Name:LY, SYLVANUS (DO)
Entity type:Individual
Prefix:DR
First Name:SYLVANUS
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7925 YOUREE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5134
Mailing Address - Country:US
Mailing Address - Phone:318-212-3610
Mailing Address - Fax:318-212-3709
Practice Address - Street 1:7925 YOUREE DR STE 200
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5134
Practice Address - Country:US
Practice Address - Phone:318-212-3610
Practice Address - Fax:318-212-3709
Is Sole Proprietor?:No
Enumeration Date:2019-05-10
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA337049207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine