MEDICARE: DR. RENE CHARLES DUFFOURC III M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	E-6696	AR
2	2084P0804X	Child & Adolescent Psychiatry Physician	E-6696	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	431560263	OTHER	AR	TRICARE

General Provider Information

NPI Number	:	1720209588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RENE CHARLES DUFFOURC III M.D.

Provider Business Mailing Address
First Line	:	PO BOX 2580
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65801-2580
Country	:	US
Telephone Number	:	417-829-4620
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 PARK DR
Second Line	:	SUITE C
City	:	HOLIDAY ISLAND
State	:	AR
Zip	:	72631-9216
Country	:	US
Telephone Number	:	479-363-9174
Fax Number	:	479-363-9175

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	03/12/2013

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