Healthcare Provider Details

I. General information

NPI: 1174064091
Provider Name (Legal Business Name): CONNIE J LI MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22542 LARK SPRING TER
DIAMOND BAR CA
91765-2956
US

IV. Provider business mailing address

22542 LARK SPRING TER
DIAMOND BAR CA
91765-2956
US

V. Phone/Fax

Practice location:
  • Phone: 909-499-6588
  • Fax:
Mailing address:
  • Phone: 909-499-6588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: CONNIE J LI
Title or Position: PRESIDENT / CEO
Credential: M.D.
Phone: 909-499-6588