Provider Demographics
NPI:1508024514
Name:SU, DIANA T (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:T
Last Name:SU
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2500 NESCONSET HWY
Mailing Address - Street 2:BLDG 12C
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790
Mailing Address - Country:US
Mailing Address - Phone:631-807-0128
Mailing Address - Fax:631-246-5817
Practice Address - Street 1:2500 NESCONSET HWY
Practice Address - Street 2:BLDG 12C
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790
Practice Address - Country:US
Practice Address - Phone:631-807-0128
Practice Address - Fax:631-246-5817
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYMD1138182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG003052486Medicaid
B13165Medicare UPIN
NYG003052486Medicaid