Provider Demographics
NPI:1245398619
Name:MUANGMAN, SUPHICHAYA (MD)
Entity Type:Individual
Prefix:
First Name:SUPHICHAYA
Middle Name:
Last Name:MUANGMAN
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 1:1625 STRAITS TPKE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-1836
Mailing Address - Country:US
Mailing Address - Phone:203-758-9100
Mailing Address - Fax:203-758-9400
Practice Address - Street 1:1625 STRAITS TPKE
Practice Address - Street 2:SUITE 209
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-1836
Practice Address - Country:US
Practice Address - Phone:203-758-9100
Practice Address - Fax:203-758-9400
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043440207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001434406Medicaid
CT010043440CT02OtherANTHEM BCBS CT
CT3V0829OtherHEALTHNET/COMMERCIAL
CT518685OtherWELLCARE
CT1105253OtherUSA
CTP00796456OtherRR MEDICARE
CTP3941581OtherOXFORD
CT043440OtherCONNECTICARE
CT001153600Medicaid
CT25-33213OtherAMERICHOICE
CT7085716OtherAETNA
CT25-33213OtherUHC
CT25-33213OtherUHC
CT060001664Medicare ID - Type Unspecified
CT518685OtherWELLCARE