Basic Information
| Provider Information | |||||||||
| NPI: | 1568435394 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LI | ||||||||
| FirstName: | FENG | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 910 E HOUSTON ST | ||||||||
| Address2: | STE 550 | ||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757028366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035108718 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 10/13/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | D67712 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | TEMP | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | N3833 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 204875301 | 05 | TX | MEDICAID | 935858-01 | 01 | MD | CAREFIRST BC/BS | OTHER | TIN PLUX 001 | 01 | TX | TRICARE TC CANTON | OTHER | 414959900 | 05 | MD | MEDICAID | TIN PLUS 028 | 01 | TX | TRICARE TC LINDALE | OTHER | S062-0329 | 01 | MD | CAREFIRST BC/BS REGIONAL | OTHER | 8BC405 | 01 | TX | BCBS OF TEXAS | OTHER | TIN PLUS 008 | 01 | TX | TRICARE | OTHER |