Provider Demographics
NPI:1265895932
Name:SURPRENANT, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:SURPRENANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 SE 4TH ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47708-1607
Mailing Address - Country:US
Mailing Address - Phone:812-463-4306
Mailing Address - Fax:
Practice Address - Street 1:120 SE 4TH ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47708-1607
Practice Address - Country:US
Practice Address - Phone:812-463-4306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35138872207N00000X
IL125070659207N00000X
IN01085760A207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology