Provider Demographics
NPI:1417525551
Name:LI, MAYLEA (OD)
Entity Type:Individual
Prefix:DR
First Name:MAYLEA
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 1:301 JAYNE AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-3369
Mailing Address - Country:US
Mailing Address - Phone:206-883-8803
Mailing Address - Fax:
Practice Address - Street 1:10520 EL DIENTE CT STE A
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80112-2656
Practice Address - Country:US
Practice Address - Phone:720-414-5310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT0003703152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist