Healthcare Provider Details

I. General information

NPI: 1003435967
Provider Name (Legal Business Name): JIEWEN LI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7595 ANAGRAM DR
EDEN PRAIRIE MN
55344-7399
US

IV. Provider business mailing address

7595 ANAGRAM DR
EDEN PRAIRIE MN
55344-7399
US

V. Phone/Fax

Practice location:
  • Phone: 612-573-2200
  • Fax: 612-573-2274
Mailing address:
  • Phone: 612-573-2200
  • Fax: 612-573-2274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number34.018252
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number81780
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: