Provider Demographics
NPI:1871672980
Name:ANNA SUPONYA MEDICAL PRACTICE, PLLC
Entity type:Organization
Organization Name:ANNA SUPONYA MEDICAL PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUPONYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-238-8373
Mailing Address - Street 1:9920 4TH AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-8328
Mailing Address - Country:US
Mailing Address - Phone:718-238-8373
Mailing Address - Fax:718-238-8375
Practice Address - Street 1:9920 4TH AVE STE 206
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-8328
Practice Address - Country:US
Practice Address - Phone:718-238-8373
Practice Address - Fax:718-238-8375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229325261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02575588Medicaid
NY208AKIMedicare ID - Type Unspecified
NY02575588Medicaid