Basic Information
| Provider Information | |||||||||
| NPI: | 1225029440 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SU | ||||||||
| FirstName: | ANDY | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4301 NORTHSTAR WAY | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953569262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Practice Location | |||||||||
| Address1: | 1420 N TRACY BLVD | ||||||||
| Address2: | |||||||||
| City: | TRACY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953763451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098326018 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 04/07/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | A69334 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | OOA693340 | 01 | CA | BLUE SHIELD | OTHER | OOA693340 | 05 | CA | MEDICAID |