Basic Information
| Provider Information | |||||||||
| NPI: | 1972999548 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SUN | ||||||||
| FirstName: | TONG | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 934 DANIELS FARM RD # A | ||||||||
| Address2: | |||||||||
| City: | TRUMBULL | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066112615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178206693 | ||||||||
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| Practice Location | |||||||||
| Address1: | 310 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037853624 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2015 | ||||||||
| LastUpdateDate: | 07/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 264359 | MA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 66454 | CT | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 1972999548 | 05 | CT | MEDICAID |