Provider Demographics
NPI:1336601558
Name:SUPER, ERIC (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:SUPER
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 1:2817 REILLY ST
Mailing Address - Street 2:
Mailing Address - City:FORT LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:28310-7324
Mailing Address - Country:US
Mailing Address - Phone:910-907-8922
Mailing Address - Fax:910-907-6069
Practice Address - Street 1:2817 REILLY ST
Practice Address - Street 2:
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310-6687
Practice Address - Country:US
Practice Address - Phone:910-907-8922
Practice Address - Fax:910-907-6069
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101270191171000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program