Provider Demographics
NPI:1558457200
Name:SU, SHIDONG (MD)
Entity Type:Individual
Prefix:
First Name:SHIDONG
Middle Name:
Last Name:SU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:136 21 ROOSEVELT AVENUE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354
Mailing Address - Country:US
Mailing Address - Phone:718-888-1803
Mailing Address - Fax:718-888-0957
Practice Address - Street 1:136 21 ROOSEVELT AVENUE
Practice Address - Street 2:SUITE 305
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354
Practice Address - Country:US
Practice Address - Phone:718-888-1803
Practice Address - Fax:718-888-0957
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2150432084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02159286Medicaid
NY05353OtherGHI-MEDICARE
NY05353OtherGHI-MEDICARE
NYH41923Medicare UPIN