Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RG0100X | Gastroenterologist | 01082091 | IN |
Y | 207RG0100X | Gastroenterologist | 01082091A | IN |
NPI | 1043641475 |
---|---|
Provider Name | Zhaodong Li |
First Address | Fort Wayne, IN 46845-1703 |
Second Address | Fort Wayne, IN 46845-1733 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/12/2013 |
Last Update Date | 26/07/2019 |