Provider Demographics
NPI:1730300641
Name:WANG, SU (MD)
Entity Type:Individual
Prefix:DR
First Name:SU
Middle Name:
Last Name:WANG
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:PO BOX 3396
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3396
Mailing Address - Country:US
Mailing Address - Phone:503-215-4323
Mailing Address - Fax:503-215-0297
Practice Address - Street 1:9205 SW BARNES RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6603
Practice Address - Country:US
Practice Address - Phone:503-215-4323
Practice Address - Fax:503-215-0297
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24780207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR117414Medicare ID - Type UnspecifiedPSH MEDICARE #
OR118080Medicare ID - Type UnspecifiedPNH MEDICARE #
OR117402Medicare ID - Type UnspecifiedPSTV MEDICARE #
OR117406Medicare ID - Type UnspecifiedPPMC MEDICARE #
ORH65351Medicare UPIN
OR117404Medicare ID - Type UnspecifiedPMH MEDICARE #