Provider Demographics
NPI:1982088852
Name:LI, JASON (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BREWSTER ST
Mailing Address - Street 2:FCC-C
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-4474
Mailing Address - Country:US
Mailing Address - Phone:401-729-2769
Mailing Address - Fax:
Practice Address - Street 1:111 BREWSTER ST
Practice Address - Street 2:FCC-C
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4474
Practice Address - Country:US
Practice Address - Phone:401-729-2769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP03490207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIRES000Medicare UPIN