=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790707271
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHANG QING LI OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2006
-----------------------------------------------------
Last Update Date | 04/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 CANAL ST RM 503
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10013-4160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-513-1338
-----------------------------------------------------
Fax | 212-619-2838
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 WITHERSPOON WAY
-----------------------------------------------------
City | MARLBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07746-2708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-431-2708
-----------------------------------------------------
Fax | 732-431-2708
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OA00601700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TUV005757
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------