Provider Demographics
NPI:1215954755
Name:DUPRE, NICOLE FAWN (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:FAWN
Last Name:DUPRE
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 1:14493 SPID DR STE A
Mailing Address - Street 2:#380
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78418-5939
Mailing Address - Country:US
Mailing Address - Phone:361-445-9306
Mailing Address - Fax:
Practice Address - Street 1:5950 SARATOGA BLVD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-4100
Practice Address - Country:US
Practice Address - Phone:361-985-5811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34812207P00000X
NE22275207P00000X
TXM1663207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176537202Medicaid
TX176537201Medicaid
TX8G1521Medicare PIN
TX8D9306Medicare PIN
TX8D8852Medicare PIN
H71151Medicare UPIN