Provider Demographics
NPI: | 1306868179 |
---|---|
Name: | LO, BETTY PEYTI (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | BETTY |
Middle Name: | PEYTI |
Last Name: | LO |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1340 POYDRAS ST |
Mailing Address - Street 2: | SUITE 1640 |
Mailing Address - City: | NEW ORLEANS |
Mailing Address - State: | LA |
Mailing Address - Zip Code: | 70112-1221 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 504-412-1835 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 200 W ESPLANADE AVE |
Practice Address - Street 2: | SUITE 205 |
Practice Address - City: | KENNER |
Practice Address - State: | LA |
Practice Address - Zip Code: | 70065-2489 |
Practice Address - Country: | US |
Practice Address - Phone: | 504-412-1705 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-24 |
Last Update Date: | 2008-10-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
LA | 09854R | 207R00000X, 208000000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
LA | 1986496 | Medicaid | |
LA | 07400536 | Medicaid | |
LA | 1986496 | Medicaid | |
LA | 07400536 | Medicaid | |
LA | 5Y642F669 | Medicare PIN | |
G53559 | Medicare UPIN |