Provider Demographics
NPI:1972701936
Name:SUPAN, MARK ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANDREW
Last Name:SUPAN
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 1:220 J L WHITE DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-4893
Mailing Address - Country:US
Mailing Address - Phone:706-692-3539
Mailing Address - Fax:
Practice Address - Street 1:220 J L WHITE DR
Practice Address - Street 2:SUITE 120
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-4893
Practice Address - Country:US
Practice Address - Phone:706-635-3539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065503207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology