Provider Demographics
NPI:1790459238
Name:LI, MING XUAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MING XUAN
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:SEAN
Other - Middle Name:
Other - Last Name:LI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:93 MADISON ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-7239
Mailing Address - Country:US
Mailing Address - Phone:857-350-5271
Mailing Address - Fax:
Practice Address - Street 1:4501 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-1205
Practice Address - Country:US
Practice Address - Phone:718-879-8171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-08
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV009379-01152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty