Provider Demographics
NPI:1588649297
Name:SU, AMBROSE K (DPM)
Entity Type:Individual
Prefix:
First Name:AMBROSE
Middle Name:K
Last Name:SU
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 NE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3543
Mailing Address - Country:US
Mailing Address - Phone:541-388-2861
Mailing Address - Fax:541-382-6297
Practice Address - Street 1:2408 NE DIVISION ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3543
Practice Address - Country:US
Practice Address - Phone:541-388-2861
Practice Address - Fax:541-382-6297
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDPOO159213E00000X
ORDP00159213E00000X, 213ES0000X, 213ES0131X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR024734001OtherBLUE CROSS
OR480031260OtherRR MEDICARE
OR13578OtherCLEAR CHOICE HEALTH PLANS
OR214619Medicaid
OR024734001OtherBLUE CROSS
OR480031260OtherRR MEDICARE