Provider Demographics
NPI:1356375059
Name:LI, MARK W (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:LI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2440 S HACIENDA BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-4763
Mailing Address - Country:US
Mailing Address - Phone:626-330-6003
Mailing Address - Fax:626-330-8474
Practice Address - Street 1:2440 S HACIENDA BLVD STE 105
Practice Address - Street 2:
Practice Address - City:HACIENDA HTS
Practice Address - State:CA
Practice Address - Zip Code:91745-4763
Practice Address - Country:US
Practice Address - Phone:626-330-6003
Practice Address - Fax:626-330-8474
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG44985207RG0100X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G449850Medicaid
CAB57514Medicare UPIN
CAG44985AMedicare ID - Type Unspecified