Provider Demographics
NPI:1154463149
Name:LI, LEO (MD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:MD
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 6359
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90609-6359
Mailing Address - Country:US
Mailing Address - Phone:818-475-8014
Mailing Address - Fax:562-696-4238
Practice Address - Street 1:309 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4308
Practice Address - Country:US
Practice Address - Phone:818-475-8014
Practice Address - Fax:562-696-4238
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG82244207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954767156OtherTAX ID
CA00G822440Medicaid
CA00G822440Medicaid
CAG82244Medicare ID - Type Unspecified
CACV113ZMedicare PIN