Provider Demographics
NPI:1043439748
Name:HSU, JOHN W (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:HSU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHNNY
Other - Middle Name:W
Other - Last Name:HSU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:200 E PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3089
Mailing Address - Country:US
Mailing Address - Phone:309-676-8123
Mailing Address - Fax:309-676-8455
Practice Address - Street 1:200 E PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3089
Practice Address - Country:US
Practice Address - Phone:309-676-8123
Practice Address - Fax:309-676-8455
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43890204F00000X
PAMD433479208600000X
IL036129902204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102548086Medicaid
AZ569040Medicaid
202466OtherMEDICARE PTAN
AZZ141254Medicare PIN