Provider Demographics
NPI:1225004252
Name:SOUPHIS, DANIEL C (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:C
Last Name:SOUPHIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4190 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3882
Mailing Address - Country:US
Mailing Address - Phone:810-989-7788
Mailing Address - Fax:810-989-7799
Practice Address - Street 1:4190 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3882
Practice Address - Country:US
Practice Address - Phone:810-989-7788
Practice Address - Fax:810-989-7799
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011575207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1225004252Medicaid
MI1225004252Medicaid