Provider Demographics
NPI:1932329414
Name:LODI MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:LODI MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACIANO
Authorized Official - Middle Name:B
Authorized Official - Last Name:DICHOSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-948-1555
Mailing Address - Street 1:402 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:OH
Mailing Address - Zip Code:44254-1216
Mailing Address - Country:US
Mailing Address - Phone:330-948-1555
Mailing Address - Fax:330-948-2676
Practice Address - Street 1:402 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:OH
Practice Address - Zip Code:44254-1216
Practice Address - Country:US
Practice Address - Phone:330-948-1555
Practice Address - Fax:330-948-2676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35033396207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0185508Medicaid
OHDI0370791Medicare ID - Type Unspecified
OH0185508Medicaid