Provider Demographics
NPI:1649376922
Name:SOOKKASIKON, SUPAK (MD)
Entity type:Individual
Prefix:
First Name:SUPAK
Middle Name:
Last Name:SOOKKASIKON
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 1:4050 W MAPLE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BLOOMFIELD TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48301-3148
Mailing Address - Country:US
Mailing Address - Phone:248-885-8211
Mailing Address - Fax:248-885-8357
Practice Address - Street 1:4050 W MAPLE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BLOOMFIELD TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48301-3148
Practice Address - Country:US
Practice Address - Phone:248-885-8211
Practice Address - Fax:248-885-8357
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083253207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5315028426OtherCONTROLLED SUBSTANCE