Provider Demographics
NPI:1255547725
Name:SU, JOHANNA (MD)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:SU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 LAGUNA RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3601
Mailing Address - Country:US
Mailing Address - Phone:714-992-5350
Mailing Address - Fax:714-992-8156
Practice Address - Street 1:101 LAGUNA RD STE 100
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3601
Practice Address - Country:US
Practice Address - Phone:714-992-5350
Practice Address - Fax:714-992-8156
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085979207V00000X
CAA 107493207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW2940AMedicare PIN
CAW2940Medicare PIN
CAFW881Medicare PIN