MEDICARE: MEDARDO C. SUPNET M.D.

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	208000000X	Pediatrics Physician	A46203	CA
2	174400000X	Specialist	A46203	CA

General Provider Information

NPI Number	:	1992817860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEDARDO C. SUPNET M.D.

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	12/15/2025

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