Provider Demographics
NPI:1316047855
Name:LI, YAN (OD)
Entity type:Individual
Prefix:
First Name:YAN
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 HOULTON ST
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-1901
Mailing Address - Country:US
Mailing Address - Phone:781-964-3840
Mailing Address - Fax:
Practice Address - Street 1:101 COMMERCE WAY
Practice Address - Street 2:TARGET OPTICAL
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1007
Practice Address - Country:US
Practice Address - Phone:781-904-0005
Practice Address - Fax:781-904-0007
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4235152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW16341OtherBCBS
MA0399868Medicaid
U84801Medicare UPIN
MAW17361Medicare ID - Type Unspecified