1760453922 NPI number — LARRY J LO MD INC

Table of content: (NPI 1760453922)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760453922 NPI number — LARRY J LO MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LARRY J LO MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760453922
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
632 W 11TH ST
Provider Second Line Business Mailing Address:
SUITE 119
Provider Business Mailing Address City Name:
TRACY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95376-3856
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-229-3700
Provider Business Mailing Address Fax Number:
209-229-3755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
632 W 11TH ST
Provider Second Line Business Practice Location Address:
SUITE 119
Provider Business Practice Location Address City Name:
TRACY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95376-3856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-229-3700
Provider Business Practice Location Address Fax Number:
209-229-3755
Provider Enumeration Date:
01/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LO
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
209-229-3700

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  G54156 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G541560 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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