Healthcare Provider Details

I. General information

NPI: 1801236641
Provider Name (Legal Business Name): NISSI SHARON SUPPOGU M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3828 SCHAUFELE AVE, STE. 250
LONG BEACH CA
90808
US

IV. Provider business mailing address

3828 SCHAUFELE AVE, STE. 250
LONG BEACH CA
90808
US

V. Phone/Fax

Practice location:
  • Phone: 657-241-8990
  • Fax: 714-665-4664
Mailing address:
  • Phone: 657-241-8990
  • Fax: 714-665-4664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA146165
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA146165
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: