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General NPI Number Information
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NPI Number | 1699923235
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Entity Type | Organization
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Legal Business Name | MEDARDO C. SUPNET, M.D., INC
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Dates
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Enumeration Date | 09/08/2008
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Last Update Date | 09/08/2008
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Provider Practice Location Address
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Address Line | 3585 E IMPERIAL HWY
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City | LYNWOOD
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State | CA
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Zip | 90262-2654
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Country | US
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Telephone | 310-605-4260
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Fax | 310-605-4263
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Provider Business Mailing Address
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Address Line | 3585 E IMPERIAL HWY
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City | LYNWOOD
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State | CA
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Zip | 90262-2654
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Country | US
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Telephone | 310-605-4260
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Fax | 310-605-4263
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Authorized Official
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Title or Position | OWNER
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Name | MEDARDO C SUPNET
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Credential | M.D.
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Telephone | 310-605-4260
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A50125
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA16910
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A46203
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License Number State | CA
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