Provider Demographics
NPI:1568519635
Name:LO, GUSTAV JALIANG (MD)
Entity Type:Individual
Prefix:DR
First Name:GUSTAV
Middle Name:JALIANG
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 1:116 W MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2324
Mailing Address - Country:US
Mailing Address - Phone:231-348-2828
Mailing Address - Fax:231-348-9609
Practice Address - Street 1:116 W MITCHELL ST
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2324
Practice Address - Country:US
Practice Address - Phone:231-348-2828
Practice Address - Fax:231-348-9609
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053321208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M62080001Medicare ID - Type Unspecified
MIE19830Medicare UPIN