The main purpose of this paper was to investigate the effect of a surface plastic deformation layer introduced by multi-pass ultrasonic surface rolling (MUSR) on the mechanical and fatigue properties of HIP Ti-6Al-4V alloys. Some microscopic analysis methods (SEM, TEM and XRD) were used to characterize the modified microstructure in the material surface layer. The results indicated that the material surface layer experienced a certain extent plastic deformation, accompanied by some dense dislocations and twin generation. Moreover, surface microhardness, residual stress and roughness values of samples treated by MUSR were also greatly improved compared with that of untreated samples. Surface microhardness and compressive residual stress were increased to 435 HV and −1173 MPa, respectively. The minimum surface roughness was reduced to 0.13 μm. The maximum depth of the surface hardening layer was about 55 μm. However, the practical influence depth was about 450 μm judging from the tensile and fatigue fracture surfaces. The ultimate tensile strength of the MUSR-treated sample increased to 990 MPa from the initial 963 MPa. The fatigue strength of the MUSR-treated sample was increased by about 25% on the base of 10⁷ cycles, and the lifetime was prolonged from two times to two orders of magnitude at the applied stress amplitudes of 650–560 MPa. The improved mechanical and fatigue properties of MUSR-treated samples should be attributed to the combined effects of the increased microhardness and compressive residual stress, low surface roughness, grain refinement and micro-pore healing in the material surface-modified layer.