Chanida K Supavong, DO

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

P5896 Issued in TX

Practice address

5450 Clearfork Main St Ste 460
Fort Worth, TX 76109

Phone

(817) 423-5121

Fax

(817) 423-5122

NPI assigned

May 2, 2011

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in TX

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Osteopathy

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1304294400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1532476800000",
    "number": "1750672218",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5450 CLEARFORK MAIN ST STE 460",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "761093560",
            "telephone_number": "817-423-5121",
            "fax_number": "817-423-5122"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5450 CLEARFORK MAIN ST STE 460",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "76109",
            "telephone_number": "817-423-5121",
            "fax_number": "817-423-5122"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SUPAVONG",
        "first_name": "CHANIDA",
        "middle_name": "K",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2011-05-02",
        "last_updated": "2018-07-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "TX",
            "license": "P5896",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Sunshine Homecare Services LLC
• Sunshine Labs
• Sunshine Living Home Health LLC
• Sunspire Health Texas LLC
• Sunvalley Global Solutions LLC
• Super Plus Hospice Inc
• Renese Ann Super, LCSW
• Superb Health Care Inc
• Superb Home Health Care Agency LLC
• Superior Evaluation Services

• Family Medicine Physician in Fort Worth, TX
• Providers in Fort Worth, TX by specialty
• Family Medicine Physician in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 25, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.