Provider Demographics
NPI:1225029440
Name:SU, ANDY K (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDY
Middle Name:K
Last Name:SU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 NORTHSTAR WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9262
Mailing Address - Country:US
Mailing Address - Phone:209-342-2300
Mailing Address - Fax:209-524-4240
Practice Address - Street 1:1420 N TRACY BLVD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3451
Practice Address - Country:US
Practice Address - Phone:209-832-6018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69334207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOA693340OtherBLUE SHIELD
CAOOA693340Medicaid
CAOOA693340Medicaid
H49427Medicare UPIN