Provider Demographics
NPI:1134136328
Name:DUPRE, SIMONNE (MD)
Entity Type:Individual
Prefix:
First Name:SIMONNE
Middle Name:
Last Name:DUPRE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2666
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-8928
Mailing Address - Country:US
Mailing Address - Phone:770-389-8855
Mailing Address - Fax:770-506-7436
Practice Address - Street 1:240 CORPORATE CENTER DR
Practice Address - Street 2:SUITE D
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7214
Practice Address - Country:US
Practice Address - Phone:770-389-8855
Practice Address - Fax:770-506-7436
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0403682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00703205DMedicaid
GA26BDGJC01Medicare ID - Type Unspecified
GAF77163Medicare UPIN