Healthcare Provider Details

I. General information

NPI: 1427018274
Provider Name (Legal Business Name): DUANE WILLIAM SUPERNEAU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8415 GOODWOOD BLVD SUITE 202 B
BATON ROUGE LA
70806-7851
US

IV. Provider business mailing address

8415 GOODWOOD BLVD SUITE 202 B
BATON ROUGE LA
70806-7851
US

V. Phone/Fax

Practice location:
  • Phone: 225-765-8988
  • Fax: 225-765-1173
Mailing address:
  • Phone: 225-765-8988
  • Fax: 225-765-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number14531
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD014531
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberMD.014531
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: