Provider Demographics
NPI:1205164878
Name:SU, TERRY (MD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:SU
Suffix:
Gender:
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 1112
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-1112
Mailing Address - Country:US
Mailing Address - Phone:407-463-9588
Mailing Address - Fax:949-798-7844
Practice Address - Street 1:7350 SANDLAKE COMMONS BLVD STE 2212A
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8031
Practice Address - Country:US
Practice Address - Phone:407-463-9588
Practice Address - Fax:949-798-7844
Is Sole Proprietor?:No
Enumeration Date:2009-11-19
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110177204E00000X, 204E00000X
CODEN.002029351223S0112X
CODR.0057245204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery