Provider Demographics
NPI:1003089970
Name:MEDARDO SUPNET M.D. INC
Entity Type:Organization
Organization Name:MEDARDO SUPNET M.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAYRIT
Authorized Official - Suffix:
Authorized Official - Credentials:
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:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46203173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1417069303Medicaid