Healthcare Provider Details

I. General information

NPI: 1467424416
Provider Name (Legal Business Name): RANGSAN SUVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 LUCY LEE PARKWAY
POPLAR BLUFF MO
63901
US

IV. Provider business mailing address

2500 LUCY LEE PARKWAY
POPLAR BLUFF MO
63901
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-2585
  • Fax: 573-686-4415
Mailing address:
  • Phone: 573-686-2585
  • Fax: 573-686-4415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR5641
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: