Provider Demographics
NPI:1124158555
Name:MIKEL W LO MD, INC
Entity type:Organization
Organization Name:MIKEL W LO MD, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:LO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-877-2725
Mailing Address - Street 1:5940 N. LA CHOLLA BLVD.
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741
Mailing Address - Country:US
Mailing Address - Phone:520-877-2725
Mailing Address - Fax:520-547-0220
Practice Address - Street 1:5940 N. LA CHOLLA BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741
Practice Address - Country:US
Practice Address - Phone:520-877-2725
Practice Address - Fax:520-547-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25801207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G36520Medicare UPIN
AZ61981Medicare ID - Type Unspecified
AZG36520Medicare UPIN