Provider Demographics
NPI:1881721926
Name:SU, STEPHEN KWANSIA (DPM)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:KWANSIA
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:P.O. BOX 2517
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92814-0517
Mailing Address - Country:US
Mailing Address - Phone:714-532-6357
Mailing Address - Fax:714-532-4144
Practice Address - Street 1:715 E CHAPMAN
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-1620
Practice Address - Country:US
Practice Address - Phone:714-532-6357
Practice Address - Fax:714-532-4144
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2174213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E21740Medicaid
95-3276847OtherFEDERAL TAX ID NUMBER
CAE2174Medicare PIN
CAT19168Medicare UPIN