Healthcare Provider Details

I. General information

NPI: 1508801044
Provider Name (Legal Business Name): SUPRIYA MATHUR GIANCHANDANI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUPRIYA MATHUR MD

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4315 DIPLOMACY DR ATTN: SHERRY REEDY
ANCHORAGE AK
99508-5926
US

IV. Provider business mailing address

1050 PACIFIC COAST HIGHWAY KAISER SOUTH BAY
HARBOR CITY CA
90710
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-3971
  • Fax: 907-729-1542
Mailing address:
  • Phone: 310-517-3174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberC54613
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5042
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: