=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164483293
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARSON TAN LO MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2006
-----------------------------------------------------
Last Update Date | 08/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1331 W GRAND PKWY N STE 310
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77493-2735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-599-3222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6255 W SUNSET BLVD FL 21
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90028-7422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-860-5200
-----------------------------------------------------
Fax | 323-467-7119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | K0112
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | K0112
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------