Provider Demographics
NPI:1174878458
Name:LI, EDDIE (OD)
Entity type:Individual
Prefix:DR
First Name:EDDIE
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7525 153RD ST APT 147
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3098
Mailing Address - Country:US
Mailing Address - Phone:848-565-8904
Mailing Address - Fax:
Practice Address - Street 1:7525 153RD ST APT 147
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-3098
Practice Address - Country:US
Practice Address - Phone:848-565-8904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-23
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007896152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist