Provider Demographics
NPI:1407818370
Name:LO, JUSTIN LIEH WAI (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:LIEH WAI
Last Name:LO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 BROMFIELD RD
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:CA
Mailing Address - Zip Code:94010-6622
Mailing Address - Country:US
Mailing Address - Phone:650-280-0816
Mailing Address - Fax:
Practice Address - Street 1:2101 FOREST AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1472
Practice Address - Country:US
Practice Address - Phone:408-295-8628
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77343207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Not Answered207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A773431Medicare ID - Type Unspecified
CAH93569Medicare UPIN