Provider Demographics
NPI:1740592260
Name:JUSTIN LO MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JUSTIN LO MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:NORTHERN CALIFORNIA PAIN SPECIALIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-295-8628
Mailing Address - Street 1:2101 FOREST AVE
Mailing Address - Street 2:SUITE 220A
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1448
Mailing Address - Country:US
Mailing Address - Phone:408-295-8628
Mailing Address - Fax:408-295-8061
Practice Address - Street 1:2101 FOREST AVE
Practice Address - Street 2:SUITE 220A
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1448
Practice Address - Country:US
Practice Address - Phone:408-295-8628
Practice Address - Fax:408-295-8061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-13
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77343208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty