MEDICARE: MEDARDO SUPNET M.D. INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	173000000X	Legal Medicine	A46203	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003089970
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDARDO SUPNET M.D. INC

Provider Business Mailing Address
First Line	:	3585 E IMPERIAL HWY
Second Line	:
City	:	LYNWOOD
State	:	CA
Zip	:	90262-2654
Country	:	US
Telephone Number	:	310-605-4260
Fax Number	:	310-605-4263

Provider Business Practice Location Address
First Line	:	3585 E IMPERIAL HWY
Second Line	:
City	:	LYNWOOD
State	:	CA
Zip	:	90262-2654
Country	:	US
Telephone Number	:	310-605-4260
Fax Number	:	310-605-4263

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MELIZA DAYRIT
Credential	:
Telephone Number	:	310-605-4260

Provider Enumeration Date	:	04/10/2008
Last Update Date	:	04/10/2008

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