Provider Demographics
NPI:1679511208
Name:SUPE, DANA (MD)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:SUPE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-596-9057
Mailing Address - Fax:856-596-0837
Practice Address - Street 1:RENAISSANCE SQUARE, 141 ROUTE 70, SUITE B
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053
Practice Address - Country:US
Practice Address - Phone:856-596-9057
Practice Address - Fax:856-596-0837
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA06493000207R00000X, 207RC0200X, 207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8780102Medicaid
NJ056105BVPMedicare ID - Type Unspecified
NJ8780102Medicaid