Provider Demographics
NPI:1639334279
Name:DUPONT, COREY (PT)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:
Last Name:DUPONT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 E SHENANDOAH DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6657
Mailing Address - Country:US
Mailing Address - Phone:208-570-3004
Mailing Address - Fax:
Practice Address - Street 1:1460 E SHENANDOAH DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6657
Practice Address - Country:US
Practice Address - Phone:208-570-3004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-23
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6101225100000X
IDPT-2398225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP01610741OtherRR MEDICARE
ID1639334279-000Medicaid
ID808487601Medicaid
IDP01610741OtherRR MEDICARE
IDP01610741OtherRR MEDICARE