Provider Demographics
NPI:1154346468
Name:LI, ERIC CONRAD (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:CONRAD
Last Name:LI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 WEST CENTURY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5655
Mailing Address - Country:US
Mailing Address - Phone:310-301-8709
Mailing Address - Fax:
Practice Address - Street 1:760 WESTWOOD PLAZA
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8353
Practice Address - Country:US
Practice Address - Phone:310-825-9989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA765662084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A765660Medicaid
CAAV643ZMedicare PIN
CAI15863Medicare UPIN