Provider Demographics
NPI:1225049414
Name:SU, PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
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 1:250 PETTIT AVE
Mailing Address - Street 2:SUITE #1
Mailing Address - City:BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-3657
Mailing Address - Country:US
Mailing Address - Phone:516-783-1577
Mailing Address - Fax:516-783-1588
Practice Address - Street 1:250 PETTIT AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-3657
Practice Address - Country:US
Practice Address - Phone:516-783-1577
Practice Address - Fax:516-783-1588
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214785174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02043456Medicaid
NYH06943Medicare UPIN
NY02043456Medicaid