Provider Demographics
NPI:1629119458
Name:SUPRUN, ULANA (MD)
Entity Type:Individual
Prefix:
First Name:ULANA
Middle Name:
Last Name:SUPRUN
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 1:635 MADISON AVE
Mailing Address - Street 2:16TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-1009
Mailing Address - Country:US
Mailing Address - Phone:212-794-2500
Mailing Address - Fax:212-879-3846
Practice Address - Street 1:635 MADISON AVE
Practice Address - Street 2:16TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-1009
Practice Address - Country:US
Practice Address - Phone:212-794-2500
Practice Address - Fax:212-879-3846
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200005174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY628541Medicare UPIN