Provider Demographics
NPI:1962895425
Name:LI, CHANEL (DO)
Entity type:Individual
Prefix:
First Name:CHANEL
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60B MOTT ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4811
Mailing Address - Country:US
Mailing Address - Phone:212-796-2196
Mailing Address - Fax:212-796-2195
Practice Address - Street 1:60B MOTT ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4811
Practice Address - Country:US
Practice Address - Phone:212-796-2196
Practice Address - Fax:212-795-2195
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY293356208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program