Basic Information
Provider Information | |||||||||
NPI: | 1295919140 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LI | ||||||||
FirstName: | RONALD ALAN | ||||||||
MiddleName: | TUNG | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LI | ||||||||
OtherFirstName: | RONALD | ||||||||
OtherMiddleName: | ALAN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 6210 | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | NM | ||||||||
PostalCode: | 874996210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5056092258 | ||||||||
FaxNumber: | 5056092259 | ||||||||
Practice Location | |||||||||
Address1: | 801 W MAPLE ST | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | NM | ||||||||
PostalCode: | 874015630 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5056092000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2007 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | BP10026185 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | MD2009-0177 | NM | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 16157745 | 05 | NM |   | MEDICAID |