Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | ME 64445 | FL |
NPI | 1114990553 |
---|---|
Provider Name | Mitchell Lewis Supler |
First Address | Ocoee, FL 34761-4215 |
Second Address | Ocoee, FL 34761-4215 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/02/2006 |
Last Update Date | 28/03/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
46892 | BCBS (01) | FL |
G28217 | (02) |