Provider Demographics
NPI:1922009216
Name:SUPERSTEIN, MARK B (DPM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:SUPERSTEIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 N SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-1563
Mailing Address - Country:US
Mailing Address - Phone:931-728-3988
Mailing Address - Fax:931-728-6530
Practice Address - Street 1:108 N SPRING ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-1563
Practice Address - Country:US
Practice Address - Phone:931-728-3988
Practice Address - Fax:931-728-6530
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN246213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5097239OtherCIGNA
TN3351041Medicaid
TN48499OtherBLUE CROSS
TNT61084Medicare UPIN
TN5097239OtherCIGNA
TN3351041Medicaid