Healthcare Provider Details

I. General information

NPI: 1245301407
Provider Name (Legal Business Name): KENSON LO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 04/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 CORPORATE DR SUITE 250
LADERA RANCH CA
92694-2135
US

IV. Provider business mailing address

23321 EL TORO RD SUITES F&G
LAKE FOREST CA
92630-4825
US

V. Phone/Fax

Practice location:
  • Phone: 949-388-1798
  • Fax: 949-388-6495
Mailing address:
  • Phone: 949-388-1798
  • Fax: 949-388-6495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA87635
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: