Provider Demographics
NPI:1174581342
Name:JEANNE D. THERIOT MD APMLLC
Entity type:Organization
Organization Name:JEANNE D. THERIOT MD APMLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:DAUPHINE
Authorized Official - Last Name:THERIOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-332-2242
Mailing Address - Street 1:112 CHAMPAGNE BLVD
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-3852
Mailing Address - Country:US
Mailing Address - Phone:337-332-2242
Mailing Address - Fax:
Practice Address - Street 1:112 CHAMPAGNE BLVD
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-3852
Practice Address - Country:US
Practice Address - Phone:337-332-2242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CY11Medicare PIN