Healthcare Provider Details

I. General information

NPI: 1891905261
Provider Name (Legal Business Name): ANITA TAM SU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANITA SU MD

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 NE 47TH AVE STE. 310
PORTLAND OR
97213-2238
US

IV. Provider business mailing address

545 NE 47TH AVE STE. 310
PORTLAND OR
97213-2238
US

V. Phone/Fax

Practice location:
  • Phone: 503-238-6233
  • Fax: 503-231-7668
Mailing address:
  • Phone: 503-636-1310
  • Fax: 503-636-1310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberMD19238
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: