Provider Demographics
NPI:1184664146
Name:SU, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:SU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 DEFENSE HIGHWAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054
Mailing Address - Country:US
Mailing Address - Phone:410-721-3200
Mailing Address - Fax:410-721-2680
Practice Address - Street 1:1438 DEFENSE HIGHWAY
Practice Address - Street 2:SUITE 201
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054
Practice Address - Country:US
Practice Address - Phone:410-721-3200
Practice Address - Fax:410-721-2680
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0056977207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
407044800OtherMEDICAL ASSISTANCE
558223OtherINFORMED
1S80POtherBLUE CROSS BLUE SHIELD
F1880001OtherBCBS FEDERAL
13564OtherJOHNS HOPKINS HLTH CARE
7120279OtherAETNA
F1880001OtherCAREFIRST
P15312OtherBCBS MPOS
MD407048800Medicaid
4301934OtherCIGNA
F1880001OtherBLUE CHOICE
165131OtherCOVENTRY HEALTH
223342OtherMAMSI
223342OtherALLIANCE