Basic Information
| Provider Information | |||||||||
| NPI: | 1134338908 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUPLICY | ||||||||
| FirstName: | FELIPE | ||||||||
| MiddleName: | PORTO DE SOUZA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 NW 51ST ST | ||||||||
| Address2: | 120 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326064333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084891187 | ||||||||
| FaxNumber: | 3522653285 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 N DIVISION ST NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084891187 | ||||||||
| FaxNumber: | 3522653285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 07/22/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 64763 | GA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | MDR-4822 | HI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084F0202X | TRN14128 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Forensic Psychiatry |
No ID Information.