Provider Demographics
NPI:1497851000
Name:SUN, ANDREW SO (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:SO
Last Name:SUN
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 1:288 S SAN GABRIEL BLVD
Mailing Address - Street 2:206
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-1667
Mailing Address - Country:US
Mailing Address - Phone:626-308-0660
Mailing Address - Fax:
Practice Address - Street 1:288 S SAN GABRIEL BLVD
Practice Address - Street 2:206
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1667
Practice Address - Country:US
Practice Address - Phone:626-308-0660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG13537207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG13537OtherSTATE LICENSE
CAG13537OtherSTATE LICENSE