Provider Demographics
NPI:1891783775
Name:SU, ANTONIUS (DPM)
Entity Type:Individual
Prefix:
First Name:ANTONIUS
Middle Name:
Last Name:SU
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 N DOBSON RD
Mailing Address - Street 2:SUITE D-71
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-4226
Mailing Address - Country:US
Mailing Address - Phone:480-963-9000
Mailing Address - Fax:480-963-0375
Practice Address - Street 1:595 N DOBSON RD
Practice Address - Street 2:SUITE D-71
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-4226
Practice Address - Country:US
Practice Address - Phone:480-963-9000
Practice Address - Fax:480-963-0375
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0496213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1Z2392OtherHEALTHNET
AZ139148Medicaid
AZAZ0193890OtherBLUE CROSS BLUE SHIELD
AZAZ0193890OtherBLUE CROSS BLUE SHIELD
AZU50072Medicare UPIN
AZ139148Medicaid
AZZ60981Medicare PIN