Provider Demographics
NPI:1699923235
Name:MEDARDO C. SUPNET, M.D., INC
Entity type:Organization
Organization Name:MEDARDO C. SUPNET, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEDARDO
Authorized Official - Middle Name:C
Authorized Official - Last Name:SUPNET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-605-4260
Mailing Address - Street 1:3585 E IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-2654
Mailing Address - Country:US
Mailing Address - Phone:310-605-4260
Mailing Address - Fax:310-605-4263
Practice Address - Street 1:3585 E IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2654
Practice Address - Country:US
Practice Address - Phone:310-605-4260
Practice Address - Fax:310-605-4263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50125174400000X
CAA46203174400000X
CAPA16910363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16910OtherPHYSICIAN ASSISTANT PROVIDER NUMBER
CA00A462030OtherMEDICAL RENDERING PROVIDER NUMBER
CA00A501250OtherMEDICAL RENDERING PROVIDER NUMBER