Provider Demographics
NPI:1477954378
Name:SUPANSIC, ANGELICA IRENE (DO)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:IRENE
Last Name:SUPANSIC
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 BENNETT AVE
Mailing Address - Street 2:LIGHTHOUSE PEDIATRICS
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-3803
Mailing Address - Country:US
Mailing Address - Phone:212-781-0800
Mailing Address - Fax:
Practice Address - Street 1:160 BENNETT AVE
Practice Address - Street 2:LIGHTHOUSE PEDIATRICS
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-3803
Practice Address - Country:US
Practice Address - Phone:212-781-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY280787208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program