Healthcare Provider Details

I. General information

NPI: 1265181408
Provider Name (Legal Business Name): KAIWEN SU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6303 LITTLE RIVER TPKE STE 300
ALEXANDRIA VA
22312-5045
US

IV. Provider business mailing address

6303 LITTLE RIVER TPKE STE 300
ALEXANDRIA VA
22312-5045
US

V. Phone/Fax

Practice location:
  • Phone: 703-914-8989
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101285905
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: