Provider Demographics
NPI:1639268592
Name:LI, LUCINDA (OD)
Entity Type:Individual
Prefix:DR
First Name:LUCINDA
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 1:1018 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-4117
Mailing Address - Country:US
Mailing Address - Phone:858-272-6843
Mailing Address - Fax:858-272-8143
Practice Address - Street 1:1018 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-4117
Practice Address - Country:US
Practice Address - Phone:858-272-6843
Practice Address - Fax:858-272-8143
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2011-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT10798T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD001150Medicaid
CAU63792Medicare UPIN
CAGSD001150Medicaid