=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689789380
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES S LI M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2006
-----------------------------------------------------
Last Update Date | 12/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7647 W GULF TO LAKE HWY SUITE 6
-----------------------------------------------------
City | CRYSTAL RIVER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34429-7962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-795-1718
-----------------------------------------------------
Fax | 352-795-7898
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7647 W GULF TO LAKE HWY SUITE 6
-----------------------------------------------------
City | CRYSTAL RIVER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34429-7962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-795-1718
-----------------------------------------------------
Fax | 352-795-7898
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | ME0029731
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------