Provider Demographics
NPI:1699867390
Name:LI, YONGXIN (MD)
Entity type:Individual
Prefix:DR
First Name:YONGXIN
Middle Name:
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:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1245
Mailing Address - Country:US
Mailing Address - Phone:803-395-4497
Mailing Address - Fax:803-395-2237
Practice Address - Street 1:1750 VILLAGE PARK DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2457
Practice Address - Country:US
Practice Address - Phone:803-395-4160
Practice Address - Fax:803-531-8810
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20072207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20072-1Medicaid
SC20072-1Medicaid
SC20072-1Medicaid