Healthcare Provider Details

I. General information

NPI: 1194385690
Provider Name (Legal Business Name): AUSTIN GEORGE DUPONT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 N 3RD ST
MACCLENNY FL
32063-2103
US

IV. Provider business mailing address

159 N 3RD ST
MACCLENNY FL
32063-2103
US

V. Phone/Fax

Practice location:
  • Phone: 904-259-7815
  • Fax: 904-774-0001
Mailing address:
  • Phone: 419-259-7815
  • Fax: 904-774-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME157220
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: