Provider Demographics
NPI:1902943483
Name:SUPANEKAR, JYOTI HARSH (MD)
Entity Type:Individual
Prefix:DR
First Name:JYOTI
Middle Name:HARSH
Last Name:SUPANEKAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7969 ASHTON AVE
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-2885
Mailing Address - Country:US
Mailing Address - Phone:703-792-7800
Mailing Address - Fax:703-792-7800
Practice Address - Street 1:15941 DONALD CURTIS DR
Practice Address - Street 2:SUITE 200
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-4256
Practice Address - Country:US
Practice Address - Phone:703-792-4900
Practice Address - Fax:703-792-7057
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102384932084P0800X
DCMD0359272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
I39529Medicare UPIN
017768K92Medicare ID - Type Unspecified