Provider Demographics
NPI:1659823128
Name:LODESPOTO MEDICAL, PLLC
Entity Type:Organization
Organization Name:LODESPOTO MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LODESPOTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-503-4419
Mailing Address - Street 1:PO BOX 958
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-0811
Mailing Address - Country:US
Mailing Address - Phone:972-503-4419
Mailing Address - Fax:844-753-4371
Practice Address - Street 1:100 CONGRESS AVE STE 2000
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-2745
Practice Address - Country:US
Practice Address - Phone:972-503-4419
Practice Address - Fax:844-753-4371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-31
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty