Provider Demographics
NPI:1114990553
Name:SUPLER, MITCHELL LEWIS (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:LEWIS
Last Name:SUPLER
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 1:10000 W COLONIAL DR STE 284
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-3432
Mailing Address - Country:US
Mailing Address - Phone:321-841-1570
Mailing Address - Fax:321-841-8185
Practice Address - Street 1:10000 W COLONIAL DR STE 284
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-3432
Practice Address - Country:US
Practice Address - Phone:321-841-1570
Practice Address - Fax:321-841-8185
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 64445207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119418200Medicaid
FL46892OtherBCBS
FL46892XMedicare PIN