Healthcare Provider Details

I. General information

NPI: 1982194262
Provider Name (Legal Business Name): JOE SU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2018
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13620 38TH AVE
FLUSHING NY
11354-4277
US

IV. Provider business mailing address

13620 38TH AVE
FLUSHING NY
11354-4277
US

V. Phone/Fax

Practice location:
  • Phone: 718-661-9554
  • Fax:
Mailing address:
  • Phone: 646-267-9142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number312207
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: