Provider Demographics
NPI:1356488332
Name:SU, ALLEN D (MD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:D
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 1:400 W ARBROOK BLVD STE 240
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76014-3107
Mailing Address - Country:US
Mailing Address - Phone:817-467-0240
Mailing Address - Fax:817-472-9385
Practice Address - Street 1:400 W ARBROOK BLVD STE 240
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-3107
Practice Address - Country:US
Practice Address - Phone:817-467-0240
Practice Address - Fax:817-472-9385
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9222207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103018101Medicaid
TX103018104Medicaid
TX103018103Medicaid
TX0075GGOtherBLUE CROSS BLUE SHIELD TX
TXG17426Medicare UPIN
TX103018104Medicaid
TX103018103Medicaid
TXTXB108164Medicare PIN