Provider Demographics
NPI:1093135758
Name:SUE, GLORIA
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:SUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743749
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-3749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 POTRERO AVENUE
Practice Address - Street 2:BUILDING 5, #3M
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:628-206-8814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-21
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA137626208200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program