Provider Demographics
NPI:1336193614
Name:LAU, SUSIE (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSIE
Middle Name:
Last Name:LAU
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 1:1700 E CESAR E CHAVEZ AVE
Mailing Address - Street 2:SUITE 3600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-2424
Mailing Address - Country:US
Mailing Address - Phone:323-262-0521
Mailing Address - Fax:323-262-4129
Practice Address - Street 1:1700 E CESAR E CHAVEZ AVE
Practice Address - Street 2:SUITE 3600
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2424
Practice Address - Country:US
Practice Address - Phone:323-262-0521
Practice Address - Fax:323-262-4129
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61050207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G610500Medicaid
CAG61050Medicare ID - Type Unspecified
CA00G610500Medicaid