Healthcare Provider Details

I. General information

NPI: 1669675153
Provider Name (Legal Business Name): MU SU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MEADOWS RD
BOCA RATON FL
33486-2304
US

IV. Provider business mailing address

PO BOX 198227
ATLANTA GA
30384-8227
US

V. Phone/Fax

Practice location:
  • Phone: 561-955-4730
  • Fax: 561-955-2127
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME 109094
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberME 109094
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberME 109094
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: