Provider Demographics
NPI:1407288327
Name:DIANE LI MD, INC
Entity Type:Organization
Organization Name:DIANE LI MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-490-8390
Mailing Address - Street 1:1000 NEWBURY RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-6435
Mailing Address - Country:US
Mailing Address - Phone:805-490-8390
Mailing Address - Fax:
Practice Address - Street 1:1000 NEWBURY RD
Practice Address - Street 2:SUITE 115
Practice Address - City:NEWBURY PARK
Practice Address - State:CA
Practice Address - Zip Code:91320-6435
Practice Address - Country:US
Practice Address - Phone:805-490-8390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86068207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA86068OtherCALIFORNIA MEDICAL LICENSE