Provider Demographics
NPI:1437141918
Name:SU, KENNY C (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNY
Middle Name:C
Last Name:SU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CHIEN-TZU
Other - Middle Name:
Other - Last Name:SU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3120 S HACIENDA BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-6305
Mailing Address - Country:US
Mailing Address - Phone:626-855-1091
Mailing Address - Fax:626-369-5988
Practice Address - Street 1:3120 S HACIENDA BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-6305
Practice Address - Country:US
Practice Address - Phone:626-855-1091
Practice Address - Fax:626-369-5988
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43900207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A439000Medicaid
CAA43900Medicare PIN
CA00A439000Medicaid