MEDICARE: DR. SUPAKUNYA EDMONSON D.O.

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	2084N0400X	Neurology Physician	2022046492	MO
2	2084N0400X	Neurology Physician	0102201767	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C06778	OTHER	VA	GROUP PTAN

General Provider Information

NPI Number	:	1366420853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUPAKUNYA EDMONSON D.O.

Provider Business Mailing Address
First Line	:	1714 POMPEY ST
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-6514
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	USS ENTERPRISE
Second Line	:	MEDICAL DEPT
City	:	NORFOLK
State	:	VA
Zip	:	23551-0001
Country	:	US
Telephone Number	:	757-444-8632
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2006
Last Update Date	:	05/14/2026

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