Provider Demographics
NPI:1063705820
Name:LO, CHUNG-CHIEH (MD)
Entity type:Individual
Prefix:
First Name:CHUNG-CHIEH
Middle Name:
Last Name:LO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JASON
Other - Middle Name:
Other - Last Name:LO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 208357
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-8357
Mailing Address - Country:US
Mailing Address - Phone:512-485-7208
Mailing Address - Fax:844-364-8678
Practice Address - Street 1:3101 HIGHWAY 71 E STE 211
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-5157
Practice Address - Country:US
Practice Address - Phone:855-876-7246
Practice Address - Fax:855-277-5070
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP1 - 0040943207X00000X
TXS0499208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBP1 - 0040943OtherPIT PERMIT NUMBER
TXS0499OtherTEXAS MEDICAL LICENSE
TX1K5259OtherTEXAS MEDICARE