Provider Demographics
NPI:1598897977
Name:SUN, RUIDONG (MD)
Entity Type:Individual
Prefix:
First Name:RUIDONG
Middle Name:
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 1:10351 DAWSONS CREEK BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1904
Mailing Address - Country:US
Mailing Address - Phone:260-969-1950
Mailing Address - Fax:
Practice Address - Street 1:700 BROADWAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-1402
Practice Address - Country:US
Practice Address - Phone:260-969-1950
Practice Address - Fax:260-969-0988
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063317207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200856520Medicaid
IN000000511776OtherANTHEM
INP00379083OtherRAILROAD MEDICARE
IN000000511776OtherANTHEM
IN249110FMedicare PIN