Healthcare Provider Details

I. General information

NPI: 1134338908
Provider Name (Legal Business Name): FELIPE PORTO DE SOUZA SUPLICY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 N DIVISION ST NW
ROME GA
30165-1454
US

IV. Provider business mailing address

4000 NW 51ST ST 120
GAINESVILLE FL
32606-4333
US

V. Phone/Fax

Practice location:
  • Phone: 808-489-1187
  • Fax: 352-265-3285
Mailing address:
  • Phone: 808-489-1187
  • Fax: 352-265-3285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberTRN14128
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number64763
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMDR-4822
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: