Provider Demographics
NPI:1942361167
Name:LI, FENGZHEN (OMD)
Entity Type:Individual
Prefix:
First Name:FENGZHEN
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 LAKESHORE AVE
Mailing Address - Street 2:100A
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-1684
Mailing Address - Country:US
Mailing Address - Phone:510-238-9675
Mailing Address - Fax:
Practice Address - Street 1:1600 LAKESHORE AVE
Practice Address - Street 2:100A
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-1684
Practice Address - Country:US
Practice Address - Phone:510-238-9675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA#3311546207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0103350OtherPROVIDER # MEDI-CAL