Provider Demographics
NPI:1124063011
Name:SUN, TONY (MD)
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:SUN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10746 PINEBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-4056
Mailing Address - Country:US
Mailing Address - Phone:225-291-6374
Mailing Address - Fax:
Practice Address - Street 1:8591 UNITED PLAZA BLVD
Practice Address - Street 2:SUITE 270
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-7007
Practice Address - Country:US
Practice Address - Phone:225-926-6353
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.10738R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1681491Medicaid
LA1681491Medicaid