Provider Demographics
NPI:1669405668
Name:LODI PLAZA HEAD & NECK MEDICAL ASSOC INC
Entity type:Organization
Organization Name:LODI PLAZA HEAD & NECK MEDICAL ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:JUNGWOOK
Authorized Official - Last Name:LIMB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-333-8510
Mailing Address - Street 1:999 S FAIRMONT AVE
Mailing Address - Street 2:#215
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240
Mailing Address - Country:US
Mailing Address - Phone:209-333-8510
Mailing Address - Fax:209-333-0966
Practice Address - Street 1:999 S FAIRMONT AVE
Practice Address - Street 2:#215
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240
Practice Address - Country:US
Practice Address - Phone:209-333-8510
Practice Address - Fax:209-333-0966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36674207Y00000X
CAG80925207Y00000X
CAA64328207Y00000X
CAA71527207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty