Provider Demographics
NPI:1750375622
Name:MA, SUN AE (OD)
Entity type:Individual
Prefix:DR
First Name:SUN AE
Middle Name:
Last Name:MA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 DEMPSTER ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-3014
Mailing Address - Country:US
Mailing Address - Phone:847-470-1115
Mailing Address - Fax:847-470-1141
Practice Address - Street 1:5901 DEMPSTER ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-3014
Practice Address - Country:US
Practice Address - Phone:847-470-1115
Practice Address - Fax:847-470-1141
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008065152W00000X
IL046-008065152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK44866Medicare PIN
T36466Medicare UPIN
ILP15656Medicare PIN