Provider Demographics
NPI:1164900700
Name:LI, DIANA (OD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 N ALPINE RD STE 121
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1439
Mailing Address - Country:US
Mailing Address - Phone:815-397-5959
Mailing Address - Fax:815-261-5971
Practice Address - Street 1:1603 N ALPINE RD STE 121
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1439
Practice Address - Country:US
Practice Address - Phone:815-397-5959
Practice Address - Fax:815-261-5971
Is Sole Proprietor?:No
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011208152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist