Basic Information
| Provider Information | |||||||||
| NPI: | 1588753354 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LO | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 GLENLAKE PKWY | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303283473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706776137 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20 GLENLAKE PKWY | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303283473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706776137 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | ME92622 | FL | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 59460 | GA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 59460 | 01 | GA | LICENSE | OTHER | ME92622 | 01 | FL | MEDICAL LICENSE | OTHER |