Basic Information
| Provider Information | |||||||||
| NPI: | 1811124217 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RONALD LO MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 STANDIFORD AVE | ||||||||
| Address2: | STE F | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953501159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095795628 | ||||||||
| FaxNumber: | 2095795637 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 14TH ST | ||||||||
| Address2: | STE 209 | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925014083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517428846 | ||||||||
| FaxNumber: | 9518480868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2009 | ||||||||
| LastUpdateDate: | 08/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | LO | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9517428846 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | A98161 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | BX522A | 01 | CA | MEDICARE GROUP # | OTHER |