Basic Information
| Provider Information | |||||||||
| NPI: | 1386752475 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LI | ||||||||
| FirstName: | SAMUEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10693 WILES RD PMB 137 | ||||||||
| Address2: | |||||||||
| City: | CORAL SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330762014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542555200 | ||||||||
| FaxNumber: | 9542552084 | ||||||||
| Practice Location | |||||||||
| Address1: | 1205 E NORTH ST | ||||||||
| Address2: | |||||||||
| City: | MANTECA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953364932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098233111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 01/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | G81427 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00G814270 | 05 | CA | MEDICAID |