Provider Demographics
NPI:1285788471
Name:TANPATTANA, SUDAPORN (OD)
Entity type:Individual
Prefix:DR
First Name:SUDAPORN
Middle Name:
Last Name:TANPATTANA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 PARSONAGE RD
Mailing Address - Street 2:UNIT 501
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837-2480
Mailing Address - Country:US
Mailing Address - Phone:732-548-7337
Mailing Address - Fax:
Practice Address - Street 1:55 PARSONAGE RD
Practice Address - Street 2:UNIT 501
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-2480
Practice Address - Country:US
Practice Address - Phone:732-548-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00594600152W00000X
NYTUV006712152W00000X
NJ27TO00133100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
087073TFOMedicare ID - Type Unspecified
U98400Medicare UPIN