Provider Demographics
NPI:1861496549
Name:SU, ANDREW T (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
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 1:4100 WEST THIRD STREET
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45428
Mailing Address - Country:US
Mailing Address - Phone:937-268-6511
Mailing Address - Fax:937-267-5316
Practice Address - Street 1:4100 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45428-9000
Practice Address - Country:US
Practice Address - Phone:937-268-6511
Practice Address - Fax:937-267-5316
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062288207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0923915Medicaid
OH0923915Medicaid
OHF65291Medicare UPIN