Healthcare Provider Details

I. General information

NPI: 1285963397
Provider Name (Legal Business Name): SUPPARERK PRICHAYUDH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2009
Last Update Date: 12/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE DEPARTMENT OF SURGERY
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1756 N BAYSHORE DR APT 29E
MIAMI FL
33132-1132
US

V. Phone/Fax

Practice location:
  • Phone: 305-335-1293
  • Fax: 305-326-7065
Mailing address:
  • Phone: 305-610-9976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: