Provider Demographics
NPI:1801236641
Name:SUPPOGU, NISSI SHARON (MD)
Entity type:Individual
Prefix:DR
First Name:NISSI
Middle Name:SHARON
Last Name:SUPPOGU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3828 SCHAUFELE AVE, STE. 200
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808
Mailing Address - Country:US
Mailing Address - Phone:657-241-8990
Mailing Address - Fax:714-665-4664
Practice Address - Street 1:3828 SCHAUFELE AVE, STE. 200
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808
Practice Address - Country:US
Practice Address - Phone:657-241-8990
Practice Address - Fax:714-665-4664
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA146165207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine