Provider Demographics
NPI:1700854833
Name:SUPINSKI, EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:SUPINSKI
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 1:6101 BLUE LAGOON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:386-676-7125
Practice Address - Street 1:3641 CLYDE MORRIS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-2357
Practice Address - Country:US
Practice Address - Phone:386-675-4410
Practice Address - Fax:866-542-5859
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 80671207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259199500Medicaid
FL35630OtherBCBS
FL259199500Medicaid
35630YMedicare ID - Type Unspecified