Provider Demographics
NPI:1316063936
Name:PAUL, SUPRITI (MD)
Entity type:Individual
Prefix:MISS
First Name:SUPRITI
Middle Name:
Last Name:PAUL
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 1:6010 HIDDEN VALLEY RD STE 210
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-4219
Mailing Address - Country:US
Mailing Address - Phone:858-755-9343
Mailing Address - Fax:858-792-1790
Practice Address - Street 1:6010 HIDDEN VALLEY RD STE 210
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-4219
Practice Address - Country:US
Practice Address - Phone:858-755-9343
Practice Address - Fax:858-792-1790
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD32356207Y00000X
CAA120434207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC323563Medicaid
SC8416Medicare PIN