Provider Demographics
NPI:1184681033
Name:DUPERVAL, JACQUES (MD)
Entity Type:Individual
Prefix:
First Name:JACQUES
Middle Name:
Last Name:DUPERVAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 PLAZA ST E
Mailing Address - Street 2:SUITE S-3
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-5040
Mailing Address - Country:US
Mailing Address - Phone:718-783-5168
Mailing Address - Fax:718-783-0408
Practice Address - Street 1:60 PLAZA ST E
Practice Address - Street 2:SUITE S-3
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-5040
Practice Address - Country:US
Practice Address - Phone:718-783-5168
Practice Address - Fax:718-783-0408
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY182104208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01476379Medicaid
NYF70850Medicare UPIN
NY01476379Medicaid