Provider Demographics
NPI:1548424229
Name:SUPHANGUL, MONTHA (MD)
Entity Type:Individual
Prefix:
First Name:MONTHA
Middle Name:
Last Name:SUPHANGUL
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 1:429 CUSTER AVE APT 2G
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2975
Mailing Address - Country:US
Mailing Address - Phone:773-273-5968
Mailing Address - Fax:
Practice Address - Street 1:355 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3328
Practice Address - Country:US
Practice Address - Phone:847-316-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125052160207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILXOF839694314OtherBLUECROSS BLUESHIELD PPO