Healthcare Provider Details

I. General information

NPI: 1609871946
Provider Name (Legal Business Name): MARK L SU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 LOW ST STE 202
NEWBURYPORT MA
01950
US

IV. Provider business mailing address

59 WASHINGTON ST
NEWBURYPORT MA
01950-2306
US

V. Phone/Fax

Practice location:
  • Phone: 978-225-0378
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number216973
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: