Provider Demographics
NPI:1689789380
Name:LI, CHARLES S (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:S
Last Name:LI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CHENG
Other - Middle Name:SHIUMN
Other - Last Name:LI
Other - Suffix:II
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7647 W GULF TO LAKE HWY
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-7962
Mailing Address - Country:US
Mailing Address - Phone:352-795-1718
Mailing Address - Fax:352-795-7898
Practice Address - Street 1:7647 W GULF TO LAKE HWY
Practice Address - Street 2:SUITE 6
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-7962
Practice Address - Country:US
Practice Address - Phone:352-795-1718
Practice Address - Fax:352-795-7898
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0029731208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL660075100Medicaid
FL035298500Medicaid
FL42122OtherBCBSFL
FL42122ZMedicare PIN
FL035298500Medicaid