Provider Demographics
NPI:1144421504
Name:LI, XINYU DANIEL (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:XINYU
Middle Name:DANIEL
Last Name:LI
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 200
Mailing Address - Street 2:
Mailing Address - City:FORT THOMPSON
Mailing Address - State:SD
Mailing Address - Zip Code:57339-0200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1323 BIA ROUTE 4
Practice Address - Street 2:
Practice Address - City:FORT THOMPSON
Practice Address - State:SD
Practice Address - Zip Code:57339-0200
Practice Address - Country:US
Practice Address - Phone:605-245-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA064592208D00000X
FLTRN 10258390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5549010Medicaid