MEDICARE: DR. MARTIN DANIEL 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	4301508399	MI

General Provider Information

NPI Number	:	1689291270
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARTIN DANIEL THERIAULT MD

Provider Business Mailing Address
First Line	:	3518 ROCHESTER RD
Second Line	:
City	:	ROYAL OAK
State	:	MI
Zip	:	48073-2815
Country	:	US
Telephone Number	:	207-239-9250
Fax Number	:

Provider Business Practice Location Address
First Line	:	3518 ROCHESTER RD
Second Line	:
City	:	ROYAL OAK
State	:	MI
Zip	:	48073-2815
Country	:	US
Telephone Number	:	207-239-9250
Fax Number	:

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

Provider Enumeration Date	:	06/29/2020
Last Update Date	:	06/04/2024

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