Provider Demographics
NPI:1578557914
Name:LO, MIKEL W (MD)
Entity Type:Individual
Prefix:
First Name:MIKEL
Middle Name:W
Last Name:LO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25801207W00000X, 207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ124361OtherHEALTHNET
AZ374223001Medicaid
AZAZ0870940OtherBCBS
AZ124361OtherHEALTHNET
AZ61981Medicare ID - Type Unspecified