Provider Demographics
NPI:1053792903
Name:DUPRE, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:DUPRE
Suffix:
Gender:M
Credentials:
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 549
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-0549
Mailing Address - Country:US
Mailing Address - Phone:260-569-9550
Mailing Address - Fax:260-569-0760
Practice Address - Street 1:935 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1740
Practice Address - Country:US
Practice Address - Phone:765-472-4344
Practice Address - Fax:765-472-7095
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003903152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201293800Medicaid
INP01562926OtherRAILROAD MEDICARE
IN201293800Medicaid
IN452570039Medicare PIN