Provider Demographics
NPI:1679507511
Name:VANASUPA, PERMPORN (MD)
Entity Type:Individual
Prefix:
First Name:PERMPORN
Middle Name:
Last Name:VANASUPA
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 1:5041 LONGVIEW DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098
Mailing Address - Country:US
Mailing Address - Phone:810-987-6200
Mailing Address - Fax:
Practice Address - Street 1:1225 10TH ST
Practice Address - Street 2:HURON FAMILY PRACTICE CENTER
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060
Practice Address - Country:US
Practice Address - Phone:810-987-6200
Practice Address - Fax:810-987-8717
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI40301032135207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAV9479088OtherUS FEDERAL
MI4301032135OtherPHYSICIAN LICENSE NUMBER
MI3184814Medicaid
MIAV9479088OtherUS FEDERAL