Basic Information
| Provider Information | |||||||||
| NPI: | 1770743593 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | XU | ||||||||
| FirstName: | SU | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 15416 N FLORIDA AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336131244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139602400 | ||||||||
| FaxNumber: | 8139602410 | ||||||||
| Practice Location | |||||||||
| Address1: | 4915 EHRLICH RD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139602400 | ||||||||
| FaxNumber: | 8139602410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2008 | ||||||||
| LastUpdateDate: | 09/12/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | ME90020 | FL | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZD0900X | ME90020 | FL | Y | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology |
ID Information
| ID | Type | State | Issuer | Description | 592235385 | 01 | FL | MULTIPLAN | OTHER | 0081220 | 01 | FL | CIGNA | OTHER | 7367680 | 01 | FL | AETNA | OTHER | 43262 | 01 | FL | FL BLUE | OTHER | 102177400 | 05 | FL | MEDICAID | 592235685 | 01 | FL | UNITED HC | OTHER |