Provider Demographics
NPI:1275576886
Name:SUPENA, RONALDO B (MD)
Entity Type:Individual
Prefix:
First Name:RONALDO
Middle Name:B
Last Name:SUPENA
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 1:611 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:SUITE 702
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2273
Mailing Address - Country:US
Mailing Address - Phone:313-832-6300
Mailing Address - Fax:313-832-8341
Practice Address - Street 1:611 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2273
Practice Address - Country:US
Practice Address - Phone:313-832-6300
Practice Address - Fax:313-832-2075
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032101207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease