Provider Demographics
NPI:1417069303
Name:MEDARDO C. SUPNET, M.D., INC
Entity Type:Organization
Organization Name:MEDARDO C. SUPNET, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEDARDO
Authorized Official - Middle Name:CABASA
Authorized Official - Last Name:SUPNET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-864-7279
Mailing Address - Street 1:11637 THE PLAZA
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-3930
Mailing Address - Country:US
Mailing Address - Phone:562-864-7279
Mailing Address - Fax:562-406-8606
Practice Address - Street 1:11637 THE PLAZA
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-3930
Practice Address - Country:US
Practice Address - Phone:562-864-7279
Practice Address - Fax:562-406-8606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGR0101320174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16910OtherPHYSICIAN ASSISTANT PROVIDER NUMBER
CA00A462030OtherMEDICAL RENDERING PROVIDER NUMBER
CA00A501250OtherMEDICAL RENDERING PROVIDER NUMBER