Provider Demographics
NPI:1043210669
Name:SUPONYA, ANNA (MD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:SUPONYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9920 4TH AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-8333
Mailing Address - Country:US
Mailing Address - Phone:718-238-8373
Mailing Address - Fax:718-238-8375
Practice Address - Street 1:9920 4TH AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-8333
Practice Address - Country:US
Practice Address - Phone:718-238-8373
Practice Address - Fax:718-238-8375
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229325-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02575588Medicaid
NY02575588Medicaid
208AK1Medicare ID - Type Unspecified