Provider Demographics
NPI:1477647238
Name:PHONSOMBAT, SUPRANEE (MD)
Entity Type:Individual
Prefix:MRS
First Name:SUPRANEE
Middle Name:
Last Name:PHONSOMBAT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2031 CROCKETT RD
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801
Mailing Address - Country:US
Mailing Address - Phone:903-729-3896
Mailing Address - Fax:903-729-2583
Practice Address - Street 1:2031 CROCKETT RD
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801
Practice Address - Country:US
Practice Address - Phone:903-729-3896
Practice Address - Fax:903-729-2583
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2852207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B25499Medicare UPIN
TX00FA62Medicare ID - Type Unspecified