Provider Demographics
NPI:1730523895
Name:LO, BENJAMIN WILLIAM
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:WILLIAM
Last Name:LO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6431 FANNIN ST
Mailing Address - Street 2:SUITE JJL 431
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1501
Mailing Address - Country:US
Mailing Address - Phone:713-500-7882
Mailing Address - Fax:713-500-0758
Practice Address - Street 1:6431 FANNIN ST
Practice Address - Street 2:SUITE JJL 431
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1501
Practice Address - Country:US
Practice Address - Phone:713-500-7882
Practice Address - Fax:713-500-0758
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ6536207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program