Healthcare Provider Details

I. General information

NPI: 1396372520
Provider Name (Legal Business Name): TIMOTHY LO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W CHARLESTON BLVD STE 230
LAS VEGAS NV
89102-2312
US

IV. Provider business mailing address

1701 W CHARLESTON BLVD STE 230
LAS VEGAS NV
89102-2312
US

V. Phone/Fax

Practice location:
  • Phone: 702-671-2329
  • Fax:
Mailing address:
  • Phone: 702-671-2329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34.016602
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: