Provider Demographics
NPI:1558394221
Name:MARY C DUPONT MD PC
Entity Type:Organization
Organization Name:MARY C DUPONT MD PC
Other - Org Name:DUPONT CENTER FOR UROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:DUPONT
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:301-654-5530
Mailing Address - Street 1:5530 WISCONSIN AVE
Mailing Address - Street 2:STE 1510
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-4404
Mailing Address - Country:US
Mailing Address - Phone:301-654-5530
Mailing Address - Fax:301-654-5540
Practice Address - Street 1:5530 WISCONSIN AVE
Practice Address - Street 2:STE 1510
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-4404
Practice Address - Country:US
Practice Address - Phone:301-654-5530
Practice Address - Fax:301-654-5540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0052162174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
340017912OtherRR MEDICARE
G02060M01Medicare ID - Type UnspecifiedPROVIDER NUMBER
340017912OtherRR MEDICARE
G02060Medicare ID - Type UnspecifiedGROUP NUMBER