Individual
ALISARA SUPTUESAT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
6411 FANNIN, HOUSTON, TX 77030
(713) 704-4000
Mailing address
P O BOX 201088, HOUSTON, TX 77216-1088
(713) 500-3500
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
42742
TX
2085R0202X
Diagnostic Radiology Physician
FTL 41869
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
187729201
—
TX
01
—
187729202
CSHCN
TX
01
—
8W2045
BCBS
TX
Enumeration date
10/04/2006
Last updated
10/13/2009
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