Healthcare Provider Details

I. General information

NPI: 1386679678
Provider Name (Legal Business Name): THOMAS SUPPAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

419 S PROSPECT ST
BURLINGTON VT
05401-3506
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-2377
  • Fax: 802-847-9644
Mailing address:
  • Phone: 802-658-0052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number042-0009724
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: