Basic Information
| Provider Information | |||||||||
| NPI: | 1902337090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LI | ||||||||
| FirstName: | JIWEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD STE 400 | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103018771 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 UCLA MEDICAL PLZ STE 420 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900958344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102066232 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2017 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A159919 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.