Provider Demographics
NPI:1689622110
Name:SU, OWEN T (MD)
Entity Type:Individual
Prefix:DR
First Name:OWEN
Middle Name:T
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 1:15 COBBLERS LN
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-5001
Mailing Address - Country:US
Mailing Address - Phone:631-499-1975
Mailing Address - Fax:
Practice Address - Street 1:60 CUTTERMILL RD
Practice Address - Street 2:507
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-3104
Practice Address - Country:US
Practice Address - Phone:516-487-8738
Practice Address - Fax:516-487-1601
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213802174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW5H781Medicare ID - Type Unspecified
NY81L301Medicare UPIN