Provider Demographics
NPI:1760987861
Name:LO, ANGELA VICTORIA (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:VICTORIA
Last Name:LO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 IRVING ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-1635
Mailing Address - Country:US
Mailing Address - Phone:516-244-8119
Mailing Address - Fax:
Practice Address - Street 1:101 NICHOLS ROAD
Practice Address - Street 2:HSC T16-020
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8160
Practice Address - Country:US
Practice Address - Phone:631-444-0580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-21739207R00000X
390200000X
NY320149207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program