Provider Demographics
NPI:1598974503
Name:SUPER, DIONE MARCUS (MD)
Entity Type:Individual
Prefix:DR
First Name:DIONE
Middle Name:MARCUS
Last Name:SUPER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1364 WELLBROOK CIR NE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3872
Mailing Address - Country:US
Mailing Address - Phone:770-285-3533
Mailing Address - Fax:770-761-7179
Practice Address - Street 1:1364 WELLBROOK CIR NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3872
Practice Address - Country:US
Practice Address - Phone:770-285-3533
Practice Address - Fax:770-761-7179
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301083750207N00000X
GA60121207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I070049Medicare UPIN