Provider Demographics
NPI:1154648210
Name:TENGSUPAKUL, SUPATIDA (MD)
Entity Type:Individual
Prefix:
First Name:SUPATIDA
Middle Name:
Last Name:TENGSUPAKUL
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:PO BOX 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-434-3626
Mailing Address - Fax:251-445-2464
Practice Address - Street 1:1601 CENTER ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-1541
Practice Address - Country:US
Practice Address - Phone:251-410-5437
Practice Address - Fax:251-434-3852
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7581208000000X, 2080P0208X
AL356322080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
No208000000XAllopathic & Osteopathic PhysiciansPediatrics