Provider Demographics
NPI:1447607049
Name:SUN, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SUN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 N PLAINS INDUSTRIAL RD BLDG 1A
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2360
Mailing Address - Country:US
Mailing Address - Phone:203-949-2700
Mailing Address - Fax:203-949-2712
Practice Address - Street 1:435 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-2101
Practice Address - Country:US
Practice Address - Phone:203-949-2700
Practice Address - Fax:203-949-2712
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT675002085N0700X, 2085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology