Provider Demographics
NPI:1730105743
Name:SU, WILLIAM T (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
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 1:11110 MEDICAL CAMPUS RD
Mailing Address - Street 2:SUITE 127
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742
Mailing Address - Country:US
Mailing Address - Phone:301-714-4335
Mailing Address - Fax:301-714-4332
Practice Address - Street 1:11110 MEDICAL CAMPUS RD
Practice Address - Street 2:SUITE 127
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742
Practice Address - Country:US
Practice Address - Phone:301-714-4335
Practice Address - Fax:301-714-4332
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0058267208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD404320100Medicaid
MD528MMedicare ID - Type Unspecified
MD404320100Medicaid