Provider Demographics
NPI:1619945391
Name:LIN, SU SU (MD)
Entity Type:Individual
Prefix:DR
First Name:SU SU
Middle Name:
Last Name:LIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:918-540-7820
Mailing Address - Fax:918-540-7819
Practice Address - Street 1:310 2ND AVE SW
Practice Address - Street 2:STE. 107-A
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-6743
Practice Address - Country:US
Practice Address - Phone:918-540-7820
Practice Address - Fax:918-540-7819
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24365207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200056600AMedicaid
OK200462050DMedicaid
OK900522214Medicare PIN
OK200056600AMedicaid
OK300522122Medicare PIN
OK299328YKW9Medicare PIN
OK200056600AMedicaid