Healthcare Provider Details

I. General information

NPI: 1699963231
Provider Name (Legal Business Name): STEPHANIE SU HUANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 MARK WEST SPRINGS RD
SANTA ROSA CA
95403-1766
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 707-541-3690
  • Fax: 707-573-5433
Mailing address:
  • Phone: 707-541-3590
  • Fax: 707-573-5433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberA91911
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA91911
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: