Provider Demographics
NPI:1609165315
Name:LUO, SU (MD)
Entity Type:Individual
Prefix:MS
First Name:SU
Middle Name:
Last Name:LUO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BELLE ISLE WAY
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02921-3542
Mailing Address - Country:US
Mailing Address - Phone:401-527-5207
Mailing Address - Fax:
Practice Address - Street 1:67 S BEDFORD ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-5108
Practice Address - Country:US
Practice Address - Phone:781-744-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA266195207ND0101X
RIMD15425207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA207N00000XOtherMEDICARE 855O