Basic Information
| Provider Information | |||||||||
| NPI: | 1720209588 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUFFOURC | ||||||||
| FirstName: | RENE | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2580 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658012580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 PARK DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | HOLIDAY ISLAND | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726319216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793639174 | ||||||||
| FaxNumber: | 4793639175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 03/12/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | E-6696 | AR | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | E-6696 | AR | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 185967001 | 05 | AR | MEDICAID | 431560263 | 01 | AR | TRICARE | OTHER |