Provider Demographics
NPI:1871589168
Name:LEAL-KHOURI, SUSANA (MD)
Entity type:Individual
Prefix:
First Name:SUSANA
Middle Name:
Last Name:LEAL-KHOURI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSANA
Other - Middle Name:
Other - Last Name:LEAL-KHOURI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:580 CRANDON BLVD
Mailing Address - Street 2:# 101
Mailing Address - City:KEY BISCAYNE
Mailing Address - State:FL
Mailing Address - Zip Code:33149-1832
Mailing Address - Country:US
Mailing Address - Phone:305-361-8200
Mailing Address - Fax:305-572-7035
Practice Address - Street 1:580 CRANDON BLVD
Practice Address - Street 2:# 101
Practice Address - City:KEY BISCAYNE
Practice Address - State:FL
Practice Address - Zip Code:33149-1832
Practice Address - Country:US
Practice Address - Phone:305-361-8200
Practice Address - Fax:305-572-7035
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46173207ND0900X, 207ZC0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02519VMedicare ID - Type Unspecified
FLD50545Medicare UPIN