Basic Information
| Provider Information | |||||||||
| NPI: | 1992708192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUPRE | ||||||||
| FirstName: | ERNEST | ||||||||
| MiddleName: | STEVE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUPRE | ||||||||
| OtherFirstName: | ERNEST | ||||||||
| OtherMiddleName: | STEVE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2229 MARY SHERMAN DR | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478827633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122683318 | ||||||||
| FaxNumber: | 8122684017 | ||||||||
| Practice Location | |||||||||
| Address1: | 2229 MARY SHERMAN DR | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478827633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122683318 | ||||||||
| FaxNumber: | 8122684017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 01/09/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01028949 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | 01028949 | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100105420B | 05 | IN | MEDICAID | 200015680A | 05 | IN | MEDICAID |