Provider Demographics
NPI:1932380698
Name:MUKHERJEE, SUPARNA
Entity Type:Individual
Prefix:
First Name:SUPARNA
Middle Name:
Last Name:MUKHERJEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337 E STATE HIGHWAY 152
Mailing Address - Street 2:SUITE 111
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-5101
Mailing Address - Country:US
Mailing Address - Phone:405-745-4786
Mailing Address - Fax:405-745-4837
Practice Address - Street 1:1337 E STATE HIGHWAY 152
Practice Address - Street 2:SUITE 111
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-5101
Practice Address - Country:US
Practice Address - Phone:405-745-4786
Practice Address - Fax:405-745-4837
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-21
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOT928225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK400522589Medicare PIN