Provider Demographics
NPI:1245379932
Name:SUPALA BERGER, AGNES Z (MD)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:Z
Last Name:SUPALA BERGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:210 BRUNSWICK AVE
Mailing Address - Street 2:
Mailing Address - City:TORONTO
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:M5S 2M5
Mailing Address - Country:CA
Mailing Address - Phone:416-922-7902
Mailing Address - Fax:416-922-7902
Practice Address - Street 1:3848 FAU BLVD STE 305
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6437
Practice Address - Country:US
Practice Address - Phone:305-243-3100
Practice Address - Fax:305-243-8108
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1574102084N0600X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY238333OtherLICENSE