Basic Information
| Provider Information | |||||||||
| NPI: | 1609165315 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUO | ||||||||
| FirstName: | SU | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 BELLE ISLE WAY | ||||||||
| Address2: | |||||||||
| City: | CRANSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029213542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015275207 | ||||||||
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| Practice Location | |||||||||
| Address1: | 67 S BEDFORD ST | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018035108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817448000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2011 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207ND0101X | 266195 | MA | Y | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207N00000X | MD15425 | RI | N | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 207N00000X | 01 | MA | MEDICARE 855O | OTHER |