Healthcare Provider Details

I. General information

NPI: 1699923235
Provider Name (Legal Business Name): MEDARDO C. SUPNET, M.D., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3585 E IMPERIAL HWY
LYNWOOD CA
90262-2654
US

IV. Provider business mailing address

3585 E IMPERIAL HWY
LYNWOOD CA
90262-2654
US

V. Phone/Fax

Practice location:
  • Phone: 310-605-4260
  • Fax: 310-605-4263
Mailing address:
  • Phone: 310-605-4260
  • Fax: 310-605-4263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA50125
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA16910
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA46203
License Number StateCA

VIII. Authorized Official

Name: MEDARDO C SUPNET
Title or Position: OWNER
Credential: M.D.
Phone: 310-605-4260