Provider Demographics
NPI:1508071507
Name:DUPONT, PAUL BRADLEY (OD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:BRADLEY
Last Name:DUPONT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4020 JACKSON STREET EXT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2701
Mailing Address - Country:US
Mailing Address - Phone:318-442-4230
Mailing Address - Fax:318-442-9537
Practice Address - Street 1:4020 JACKSON STREET EXT
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2701
Practice Address - Country:US
Practice Address - Phone:318-442-4230
Practice Address - Fax:318-442-9537
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA978263T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1397997Medicaid
LA1397997Medicaid
LA49025Medicare ID - Type Unspecified