Provider Demographics
NPI:1790707271
Name:LI, CHANG QING (OD)
Entity Type:Individual
Prefix:DR
First Name:CHANG
Middle Name:QING
Last Name:LI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:7 WITHERSPOON WAY
Mailing Address - Street 2:
Mailing Address - City:MARLBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:07746-2708
Mailing Address - Country:US
Mailing Address - Phone:732-431-2708
Mailing Address - Fax:732-431-2708
Practice Address - Street 1:210 CANAL ST RM 503
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4160
Practice Address - Country:US
Practice Address - Phone:212-513-1338
Practice Address - Fax:212-619-2838
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJOA00601700152W00000X
NYTUV005757152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01824208Medicaid
NYC508G1Medicare PIN
NY01824208Medicaid