Provider Demographics
NPI:1346417276
Name:SU, THOMAS T (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:T
Last Name:SU
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91102-0629
Mailing Address - Country:US
Mailing Address - Phone:310-528-5199
Mailing Address - Fax:
Practice Address - Street 1:633 N CENTRAL AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1801
Practice Address - Country:US
Practice Address - Phone:818-244-7281
Practice Address - Fax:818-244-5912
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-09
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA94221207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology