=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952663718
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LI SUN D.O
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2012
-----------------------------------------------------
Last Update Date | 01/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1039 AVENUE C
-----------------------------------------------------
City | BAYONNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07002-3217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-972-5568
-----------------------------------------------------
Fax | 669-204-0326
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 ROUTE 34 STE A
-----------------------------------------------------
City | MATAWAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07747-2197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-812-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 25MB10331900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------