Provider Demographics
NPI:1629150511
Name:LI, VICTOR (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
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 1:3143 PAUL SWEET RD
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1521
Mailing Address - Country:US
Mailing Address - Phone:831-464-7246
Mailing Address - Fax:831-464-7744
Practice Address - Street 1:3143 PAUL SWEET RD
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1521
Practice Address - Country:US
Practice Address - Phone:831-464-7246
Practice Address - Fax:831-464-7744
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77617207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A776170OtherBLUE SHIELD
CA00A776170Medicaid
CAA77617OtherBLUE CROSS
CAH75213Medicare UPIN
CA00A776170Medicaid