Provider Demographics
NPI:1699963231
Name:HUANG, STEPHANIE SU (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SU
Last Name:HUANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:707-541-3590
Mailing Address - Fax:707-573-5433
Practice Address - Street 1:34 MARK WEST SPRINGS RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1766
Practice Address - Country:US
Practice Address - Phone:707-541-3690
Practice Address - Fax:707-573-5433
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91911207YS0123X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00933203OtherRAILROAD MEDICARE
CA00A919110OtherBLUE SHIELD OF CALIFORNIA
CA1699963231Medicaid
CAEU953ZMedicare PIN
CAP00933203OtherRAILROAD MEDICARE