Provider Demographics
NPI:1194751727
Name:SUPANCE, JOHN STANLEY (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:STANLEY
Last Name:SUPANCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26726 CROWN VALLEY PKWY
Mailing Address - Street 2:#200
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6364
Mailing Address - Country:US
Mailing Address - Phone:949-364-4361
Mailing Address - Fax:949-364-4495
Practice Address - Street 1:26726 CROWN VALLEY PKWY
Practice Address - Street 2:#200
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6364
Practice Address - Country:US
Practice Address - Phone:949-364-4361
Practice Address - Fax:949-364-4495
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50560174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G505600Medicaid
CA00G505600Medicaid
WG50560AMedicare ID - Type Unspecified