Provider Demographics
NPI:1568435394
Name:LI, FENG (MD)
Entity Type:Individual
Prefix:
First Name:FENG
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:910 E HOUSTON ST
Practice Address - Street 2:STE 550
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8366
Practice Address - Country:US
Practice Address - Phone:903-510-8718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD67712207RG0100X
TXTEMP207RG0100X
TXN3833207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX204875301Medicaid
MD935858-01OtherCAREFIRST BC/BS
TXTIN PLUX 001OtherTRICARE TC CANTON
MD414959900Medicaid
TXTIN PLUS 028OtherTRICARE TC LINDALE
MDS062-0329OtherCAREFIRST BC/BS REGIONAL
TX8BC405OtherBCBS OF TEXAS
TXTIN PLUS 008OtherTRICARE
MDS062-0329OtherCAREFIRST BC/BS REGIONAL
TXTIN PLUS 008OtherTRICARE
TXP00736680Medicare Oscar/Certification