Provider Demographics
NPI:1255160719
Name:LODI LIFESTYLE MEDICINE & SURGERY, PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:LODI LIFESTYLE MEDICINE & SURGERY, PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-986-0802
Mailing Address - Street 1:801 S HAM LN STE E
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-7502
Mailing Address - Country:US
Mailing Address - Phone:209-333-1441
Mailing Address - Fax:209-333-1476
Practice Address - Street 1:801 S HAM LN STE E
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-7502
Practice Address - Country:US
Practice Address - Phone:209-333-1441
Practice Address - Fax:209-333-1476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty