Provider Demographics
NPI:1770914459
Name:LI, CARL
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CARL
Other - Middle Name:
Other - Last Name:LI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:270 FARBER HALL
Mailing Address - Street 2:3435 MAIN STREET
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-8001
Mailing Address - Country:US
Mailing Address - Phone:716-829-5382
Mailing Address - Fax:
Practice Address - Street 1:270 FARBER HALL
Practice Address - Street 2:3435 MAIN STREET
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-8001
Practice Address - Country:US
Practice Address - Phone:716-829-5382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-06
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214130-12083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine