Provider Demographics
NPI:1760453922
Name:LARRY J LO MD INC
Entity Type:Organization
Organization Name:LARRY J LO MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:LO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-229-3700
Mailing Address - Street 1:632 W 11TH ST
Mailing Address - Street 2:SUITE 119
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3856
Mailing Address - Country:US
Mailing Address - Phone:209-229-3700
Mailing Address - Fax:209-229-3755
Practice Address - Street 1:632 W 11TH ST
Practice Address - Street 2:SUITE 119
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3856
Practice Address - Country:US
Practice Address - Phone:209-229-3700
Practice Address - Fax:209-229-3755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG54156207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G541560Medicaid
CA00G541560Medicaid
CAZZZ29352ZMedicare ID - Type Unspecified