Provider Demographics
NPI:1669931481
Name:LI, ANITA (MD)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15870 N LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-7846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 E DOUGLAS RD STE 407
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1468
Practice Address - Country:US
Practice Address - Phone:857-249-1747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01087618A207Q00000X
NH09LIA92161207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine