Provider Demographics
NPI:1972544690
Name:SUPERVILLE, THOMAS PAUL (DC)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:PAUL
Last Name:SUPERVILLE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 HARLAND DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-1823
Mailing Address - Country:US
Mailing Address - Phone:713-812-1880
Mailing Address - Fax:173-812-1881
Practice Address - Street 1:2061 ANTOINE DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055-1840
Practice Address - Country:US
Practice Address - Phone:713-812-1880
Practice Address - Fax:713-812-1881
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4527111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX609225Medicare ID - Type Unspecified