Basic Information
| Provider Information | |||||||||
| NPI: | 1932423225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LI | ||||||||
| FirstName: | DOUGLAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1260 15TH ST STE 1024 | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904041145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108250867 | ||||||||
| FaxNumber: | 4242598571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2010 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0214X | A108116 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology | 208000000X | A108116 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0A1081160 | 05 | CA | MEDICAID |