Provider Demographics
NPI:1861451569
Name:SUPAN, SAMAI (MD)
Entity Type:Individual
Prefix:
First Name:SAMAI
Middle Name:
Last Name:SUPAN
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 1:154 SPANISH POINT DR
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-6126
Mailing Address - Country:US
Mailing Address - Phone:843-525-6569
Mailing Address - Fax:
Practice Address - Street 1:719 OKATIE HWY # 170
Practice Address - Street 2:
Practice Address - City:OKATIE
Practice Address - State:SC
Practice Address - Zip Code:29909-3963
Practice Address - Country:US
Practice Address - Phone:843-987-7400
Practice Address - Fax:843-987-5135
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11283207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC11283OtherSTATE LICENSE
SC11283OtherSTATE LICENSE