MEDICARE: DR. VICTOR GASTON THERIAULT MD

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	207Q00000X	Family Medicine Physician	014544	LA

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

General Provider Information

NPI Number	:	1396742318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VICTOR GASTON THERIAULT MD

Provider Business Mailing Address
First Line	:	712 WILLIS AVE
Second Line	:
City	:	BOGALUSA
State	:	LA
Zip	:	70427-3004
Country	:	US
Telephone Number	:	985-732-4853
Fax Number	:	985-735-8883

Provider Business Practice Location Address
First Line	:	2905 E SOUTH BLVD
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36116-2501
Country	:	US
Telephone Number	:	334-420-5001
Fax Number	:	334-420-0160

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

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	03/26/2025

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