Provider Demographics
NPI:1235142761
Name:LI, EVELYN EVENS (MD)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:EVENS
Last Name:LI
Suffix:
Gender:F
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 14858
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539
Mailing Address - Country:US
Mailing Address - Phone:510-770-1300
Mailing Address - Fax:510-573-4811
Practice Address - Street 1:46356 WARM SPRINGS BLVD
Practice Address - Street 2:872
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539-7021
Practice Address - Country:US
Practice Address - Phone:510-770-1300
Practice Address - Fax:510-573-4811
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48660174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G486600Medicaid
CAA51137Medicare UPIN
CA00G486600Medicaid