Provider Demographics
NPI:1538121579
Name:SUPPES, PATRICIA (MD PHD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:SUPPES
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 MAIN ST UNIT 394
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94023-9004
Mailing Address - Country:US
Mailing Address - Phone:650-862-2777
Mailing Address - Fax:650-849-1913
Practice Address - Street 1:221 MAIN ST UNIT 394
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94023-9004
Practice Address - Country:US
Practice Address - Phone:650-862-2777
Practice Address - Fax:650-849-1913
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ28132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103208802Medicaid
TX82G313Medicare ID - Type Unspecified
TX103208802Medicaid