MEDICARE: MIKEL W LO MD, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	25801	AZ

General Provider Information

NPI Number	:	1124158555
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIKEL W LO MD, INC

Provider Business Mailing Address
First Line	:	5940 N. LA CHOLLA BLVD.
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85741
Country	:	US
Telephone Number	:	520-877-2725
Fax Number	:	520-547-0220

Provider Business Practice Location Address
First Line	:	5940 N. LA CHOLLA BLVD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85741
Country	:	US
Telephone Number	:	520-877-2725
Fax Number	:	520-547-0220

Authorized Official
Title or Position	:	DIRECT OWNER
Name	:	DR. MIKEL W LO
Credential	:	MD
Telephone Number	:	520-877-2725

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	07/22/2014

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