Provider Demographics
NPI:1710900824
Name:HERMAN M. DUPERAULT, JR., O.D., P.A.
Entity Type:Organization
Organization Name:HERMAN M. DUPERAULT, JR., O.D., P.A.
Other - Org Name:H.M. DUPERAULT JR. O.D. P.A.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HERMAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DUPERAULT
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:904-246-0404
Mailing Address - Street 1:3078 MERRILL BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-8163
Mailing Address - Country:US
Mailing Address - Phone:904-246-0404
Mailing Address - Fax:904-246-0404
Practice Address - Street 1:447 ATLANTIC BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ATLANTIC BEACH
Practice Address - State:FL
Practice Address - Zip Code:32233-4004
Practice Address - Country:US
Practice Address - Phone:904-246-4372
Practice Address - Fax:904-246-6115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 672305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084332600Medicaid
FL084332600Medicaid