Provider Demographics
NPI:1891227211
Name:LI, JOHNNY XIANG (MD)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:XIANG
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 1:635 W 165TH ST # 96
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3724
Mailing Address - Country:US
Mailing Address - Phone:212-305-9535
Mailing Address - Fax:
Practice Address - Street 1:128 MOTT ST STE 408
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-5588
Practice Address - Country:US
Practice Address - Phone:212-732-0073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311321207W00000X, 207WX0009X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY311321OtherLICENSE