Healthcare Provider Details

I. General information

NPI: 1396742318
Provider Name (Legal Business Name): VICTOR GASTON THERIAULT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 E SOUTH BLVD
MONTGOMERY AL
36116-2501
US

IV. Provider business mailing address

712 WILLIS AVE
BOGALUSA LA
70427-3004
US

V. Phone/Fax

Practice location:
  • Phone: 334-420-5001
  • Fax: 334-420-0160
Mailing address:
  • Phone: 985-732-4853
  • Fax: 985-735-8883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number014544
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: