Provider Demographics
NPI:1730258476
Name:DUANE DECROUPET OD A PC
Entity type:Organization
Organization Name:DUANE DECROUPET OD A PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DE CROUPET
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:818-243-1300
Mailing Address - Street 1:308 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205
Mailing Address - Country:US
Mailing Address - Phone:818-243-1300
Mailing Address - Fax:818-243-1583
Practice Address - Street 1:308 E BROADWAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205
Practice Address - Country:US
Practice Address - Phone:818-243-1300
Practice Address - Fax:818-243-1583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY3496Medicare ID - Type Unspecified
CA0716810001Medicare NSC