Provider Demographics
NPI:1447207071
Name:SUPRIN, GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:SUPRIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BROADWAY
Mailing Address - Street 2:#1005
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10006-1951
Mailing Address - Country:US
Mailing Address - Phone:646-217-4610
Mailing Address - Fax:917-591-8596
Practice Address - Street 1:8810 PARSONS BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-3842
Practice Address - Country:US
Practice Address - Phone:718-291-8111
Practice Address - Fax:718-487-9343
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230165-1207Q00000X
NY230165207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02585106Medicaid
NY02585106Medicaid
NY0624P21511Medicare PIN