Basic Information
Provider Information | |||||||||
NPI: | 1407879323 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUPONT | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: | BENTON | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8490 PICARDY AVE | ||||||||
Address2: | BLDG 200 | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708093731 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2252371754 | ||||||||
FaxNumber: | 2252371722 | ||||||||
Practice Location | |||||||||
Address1: | 3401 NORTH BLVD | ||||||||
Address2: | SUITE 200-B | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708063743 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2253812615 | ||||||||
FaxNumber: | 2253812638 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2006 | ||||||||
LastUpdateDate: | 06/16/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | MD012268 | LA | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208600000X | MD012268 | LA | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 1196177 | 05 | LA |   | MEDICAID | 5DG10 | 01 | LA | MEDICARE GROUP PTAN | OTHER | 270476YUB6 | 01 | LA | MEDICARE PTAN | OTHER |