Provider Demographics
NPI:1114663572
Name:LI, ZHIYUAN (DO)
Entity Type:Individual
Prefix:
First Name:ZHIYUAN
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:KEVIN
Other - Middle Name:
Other - Last Name:LI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-3282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.082246208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics