Provider Demographics
NPI:1912995655
Name:SU, CHARLES YIENG CHU (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:YIENG CHU
Last Name:SU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 SAINT LAURENT CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-5874
Mailing Address - Country:US
Mailing Address - Phone:817-329-4792
Mailing Address - Fax:
Practice Address - Street 1:1901 N MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-2220
Practice Address - Country:US
Practice Address - Phone:972-579-8110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3383207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX089938703OtherCSHCN
TX82251FOtherBCBS
TX089938702Medicaid
TX089938703OtherCSHCN
TX930046811Medicare PIN
TXG44995Medicare UPIN