Healthcare Provider Details

I. General information

NPI: 1649582628
Provider Name (Legal Business Name): JOE LI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2010
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4877 PALM COAST PKWY NW UNIT 4
PALM COAST FL
32137-3677
US

IV. Provider business mailing address

4877 PALM COAST PKWY NW UNIT 4
PALM COAST FL
32137-3677
US

V. Phone/Fax

Practice location:
  • Phone: 386-490-9990
  • Fax: 386-263-8768
Mailing address:
  • Phone: 386-490-9990
  • Fax: 386-263-8768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901002370
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3598
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: