Basic Information
| Provider Information | |||||||||
| NPI: | 1023035573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUBAN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D., FACEP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CORPORATE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705083870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008939698 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184637311 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 03/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2002031637 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 9900480 | NC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 036-079250 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | J5749 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036079250-3 | 05 | IL | MEDICAID | 204989404 | 05 | MO | MEDICAID | 036079250 | 05 | IL | MEDICAID |