Provider Demographics
NPI:1508205311
Name:SUPPIAH, SOMU (MD)
Entity Type:Individual
Prefix:
First Name:SOMU
Middle Name:
Last Name:SUPPIAH
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 1:7401 METRO BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-3086
Mailing Address - Country:US
Mailing Address - Phone:952-920-4915
Mailing Address - Fax:
Practice Address - Street 1:6500 EXCELSIOR BLVD DEPT OF
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426
Practice Address - Country:US
Practice Address - Phone:952-993-6032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5104-8502085R0001X
MN635012085R0001X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology