Provider Demographics
NPI:1720209588
Name:DUFFOURC, RENE CHARLES III (MD)
Entity Type:Individual
Prefix:DR
First Name:RENE
Middle Name:CHARLES
Last Name:DUFFOURC
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1 PARK DR
Practice Address - Street 2:SUITE C
Practice Address - City:HOLIDAY ISLAND
Practice Address - State:AR
Practice Address - Zip Code:72631-9216
Practice Address - Country:US
Practice Address - Phone:479-363-9174
Practice Address - Fax:479-363-9175
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-66962084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR185967001Medicaid
AR431560263OtherTRICARE
AR5AG75B889Medicare PIN
LA5MO34Medicare UPIN