Provider Demographics
NPI:1609890219
Name:DUPONT, M LYNNE (MD)
Entity Type:Individual
Prefix:
First Name:M
Middle Name:LYNNE
Last Name:DUPONT
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 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:910 FOULK ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3157
Practice Address - Country:US
Practice Address - Phone:302-655-3242
Practice Address - Fax:302-655-5392
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10005471208000000X, 208D00000X
PAMD067350L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE000958201Medicaid
NJ0133345Medicaid
PA101960506Medicaid
MD412689100Medicaid
I03133Medicare UPIN
DE022013N34Medicare PIN
H62839Medicare UPIN
MD412689100Medicaid