Provider Demographics
NPI:1124465067
Name:SUPER, EILEEN NIKKO (MD)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:NIKKO
Last Name:SUPER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 BROAD ST
Mailing Address - Street 2:UNIT 303
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-8200
Mailing Address - Country:US
Mailing Address - Phone:801-916-1782
Mailing Address - Fax:
Practice Address - Street 1:3601 SW 160TH AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-6308
Practice Address - Country:US
Practice Address - Phone:877-866-7123
Practice Address - Fax:855-855-2792
Is Sole Proprietor?:No
Enumeration Date:2013-06-02
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA74602208600000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA74602OtherGEORGIA COMPOSITE MEDICAL BOARD