Healthcare Provider Details

I. General information

NPI: 1073824942
Provider Name (Legal Business Name): JICHANG LI, M.D., A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

438 W LAS TUNAS DR
SAN GABRIEL CA
91776-1216
US

IV. Provider business mailing address

PO BOX 5486
ORANGE CA
92863-5486
US

V. Phone/Fax

Practice location:
  • Phone: 626-289-5454
  • Fax:
Mailing address:
  • Phone: 818-550-0900
  • Fax: 818-550-0909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA102566
License Number StateCA

VIII. Authorized Official

Name: DR. JICHANG LI
Title or Position: PRESIDENT
Credential: MD
Phone: 818-550-0900