=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578024592
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISA YUE-TING SU MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2019
-----------------------------------------------------
Last Update Date | 09/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 W PUTNAM AVE FL 2
-----------------------------------------------------
City | GREENWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06830-2937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-925-3637
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 208071
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06520-8071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-785-2941
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XP3100X
-----------------------------------------------------
Taxonomy Name | Pediatric Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | CSP.0090486
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------