Healthcare Provider Details

I. General information

NPI: 1356375059
Provider Name (Legal Business Name): MARK W. LI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 05/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 S HACIENDA BLVD STE 105
HACIENDA HTS CA
91745-4763
US

IV. Provider business mailing address

2440 S HACIENDA BLVD STE 105
HACIENDA HTS CA
91745-4763
US

V. Phone/Fax

Practice location:
  • Phone: 626-330-6003
  • Fax: 626-330-8474
Mailing address:
  • Phone: 626-330-6003
  • Fax: 626-330-8474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberG44985
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: