Provider Demographics
NPI:1124040431
Name:LI, JUI-JUNG RAYMOND
Entity Type:Individual
Prefix:
First Name:JUI-JUNG
Middle Name:RAYMOND
Last Name:LI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3655 LOMITA BLVD STE 121
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-1908
Mailing Address - Country:US
Mailing Address - Phone:310-375-2256
Mailing Address - Fax:
Practice Address - Street 1:3655 LOMITA BLVD STE 121
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-1908
Practice Address - Country:US
Practice Address - Phone:310-375-2256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2010-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA042835207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA42835OtherMEDICARE IDENTIFICATION NUMBER-PTAN
CAA042835Medicare ID - Type Unspecified
CAA42835OtherMEDICARE IDENTIFICATION NUMBER-PTAN