Healthcare Provider Details

I. General information

NPI: 1609165315
Provider Name (Legal Business Name): SU LUO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 RESERVOIR AVE
CRANSTON RI
02910-4423
US

IV. Provider business mailing address

19 BELLE ISLE WAY
CRANSTON RI
02921-3542
US

V. Phone/Fax

Practice location:
  • Phone: 401-943-0761
  • Fax:
Mailing address:
  • Phone: 401-527-5207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD15425
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD15425
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: