Provider Demographics
NPI:1447285838
Name:LI, CHARLENE C (MD)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:C
Last Name:LI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:851 MARSHALL PHELPS ROAD
Mailing Address - Street 2:HEALTH ONE PHYSICIAN ASSOCIATES PC WINDSOR FAMILY MEDIC
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095
Mailing Address - Country:US
Mailing Address - Phone:860-683-0756
Mailing Address - Fax:860-683-1555
Practice Address - Street 1:851 MARSHALL PHELPS ROAD
Practice Address - Street 2:WINDSOR FAMILY MEDICINE
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095
Practice Address - Country:US
Practice Address - Phone:860-683-0756
Practice Address - Fax:860-683-1555
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT021556207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001215565Medicaid
CT080166654OtherRAILROAD MEDICARE
B39474Medicare UPIN
CT080001297Medicare PIN