Basic Information
| Provider Information | |||||||||
| NPI: | 1053792903 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUPRE | ||||||||
| FirstName: | ANDREW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 549 | ||||||||
| Address2: | |||||||||
| City: | WABASH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469920549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2605699550 | ||||||||
| FaxNumber: | 2605690760 | ||||||||
| Practice Location | |||||||||
| Address1: | 935 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PERU | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469701740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654724344 | ||||||||
| FaxNumber: | 7654727095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2015 | ||||||||
| LastUpdateDate: | 08/03/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18003903 | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 201293800 | 05 | IN | MEDICAID | P01562926 | 01 | IN | RAILROAD MEDICARE | OTHER |