Provider Demographics
NPI:1467424416
Name:SUVAN, RANGSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RANGSAN
Middle Name:
Last Name:SUVAN
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 1:2500 LUCY LEE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901
Mailing Address - Country:US
Mailing Address - Phone:573-686-2585
Mailing Address - Fax:573-686-4415
Practice Address - Street 1:2500 LUCY LEE PARKWAY
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901
Practice Address - Country:US
Practice Address - Phone:573-686-2585
Practice Address - Fax:573-686-4415
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5641208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200331510Medicaid
AR108033001OtherARKANSAS INDIVIDUAL MEDICAID NUMBER
MO200331510Medicaid
AR108033001OtherARKANSAS INDIVIDUAL MEDICAID NUMBER