Healthcare Provider Details

I. General information

NPI: 1740983436
Provider Name (Legal Business Name): KEVIN SU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE
NEW YORK NY
10029-7491
US

IV. Provider business mailing address

3961 48TH ST # 1R
SUNNYSIDE NY
11104-1021
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number338733
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: