Provider Demographics
NPI:1609871946
Name:SU, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:SU
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 1:59 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950-2306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 LOW ST STE 202
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950
Practice Address - Country:US
Practice Address - Phone:978-225-0378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216973207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2011450Medicaid
MAH88314Medicare UPIN
MAA35664Medicare ID - Type Unspecified