Provider Demographics
NPI:1922487800
Name:SU, JEANNIE JIWON (MD)
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:JIWON
Last Name:SU
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 1:1014 BROADWAY # 109
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-2808
Mailing Address - Country:US
Mailing Address - Phone:424-432-2304
Mailing Address - Fax:
Practice Address - Street 1:2121 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2303
Practice Address - Country:US
Practice Address - Phone:424-432-2304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-25
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA168007208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty