Healthcare Provider Details

I. General information

NPI: 1245398619
Provider Name (Legal Business Name): SUPHICHAYA MUANGMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 STRAITS TPKE SUITE 209
MIDDLEBURY CT
06762-1836
US

IV. Provider business mailing address

1625 STRAITS TPKE SUITE 209
MIDDLEBURY CT
06762-1836
US

V. Phone/Fax

Practice location:
  • Phone: 203-758-9100
  • Fax: 203-758-9400
Mailing address:
  • Phone: 203-758-9100
  • Fax: 203-758-9400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number043440
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: