Provider Demographics
NPI:1740503705
Name:LEO LI MD A MEDICAL CORPORATION
Entity type:Organization
Organization Name:LEO LI MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEO
Authorized Official - Middle Name:
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-475-8014
Mailing Address - Street 1:PO BOX 6359
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90609-6359
Mailing Address - Country:US
Mailing Address - Phone:818-475-8014
Mailing Address - Fax:562-696-4238
Practice Address - Street 1:309 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4308
Practice Address - Country:US
Practice Address - Phone:818-475-8014
Practice Address - Fax:562-696-4238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-04
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG82244174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG32904Medicare UPIN
CACV108AMedicare PIN