Provider Demographics
NPI:1538187778
Name:SUPPES, DEBORAH LEE (MD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LEE
Last Name:SUPPES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:LEE
Other - Last Name:CROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-1498
Mailing Address - Country:US
Mailing Address - Phone:507-646-1478
Mailing Address - Fax:507-646-1393
Practice Address - Street 1:2000 NORTH AVE
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-1498
Practice Address - Country:US
Practice Address - Phone:507-646-1478
Practice Address - Fax:507-646-1393
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43578207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN690929900Medicaid
160060011OtherRAIL ROAD MEDICARE