Provider Demographics
NPI:1508066705
Name:SUN, DEXTER Y (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:DEXTER
Middle Name:Y
Last Name:SUN
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 1:943 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-5107
Mailing Address - Country:US
Mailing Address - Phone:212-717-8282
Mailing Address - Fax:212-717-9643
Practice Address - Street 1:943 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-5107
Practice Address - Country:US
Practice Address - Phone:212-717-8282
Practice Address - Fax:212-717-9643
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204712174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY92Z011Medicare PIN