Healthcare Provider Details

I. General information

NPI: 1053332130
Provider Name (Legal Business Name): SUPRIYA TOMAR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 09/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 N FLAGLER DR SUITE 3900
WEST PALM BEACH FL
33401-3404
US

IV. Provider business mailing address

1411 N FLAGLER DR SUITE 3900
WEST PALM BEACH FL
33401-3404
US

V. Phone/Fax

Practice location:
  • Phone: 561-805-9399
  • Fax: 561-805-9866
Mailing address:
  • Phone: 561-805-9399
  • Fax: 561-805-9866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME88868
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberME88868
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberME88868
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: