Provider Demographics
NPI:1720021116
Name:LI, HONGTAI (MD)
Entity Type:Individual
Prefix:DR
First Name:HONGTAI
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 1:1635 DIVISADERO ST
Mailing Address - Street 2:SUITE 625, BOX 1821
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-3036
Mailing Address - Country:US
Mailing Address - Phone:415-476-4029
Mailing Address - Fax:415-476-4150
Practice Address - Street 1:505 PARNASSUS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2204
Practice Address - Country:US
Practice Address - Phone:415-353-1384
Practice Address - Fax:415-476-0616
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA668172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A668170Medicaid
CA00A668170Medicaid
CA00A668170Medicare PIN