Healthcare Provider Details

I. General information

NPI: 1336147081
Provider Name (Legal Business Name): ANTHONY COLLINS THIBODEAUX M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 08/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4630 AMBASSADOR CAFFERY PKWY STE 208
LAFAYETTE LA
70508-6949
US

IV. Provider business mailing address

4809 AMBASSADOR CAFFERY PKWY SUITE 200
LAFAYETTE LA
70508-6917
US

V. Phone/Fax

Practice location:
  • Phone: 337-981-6100
  • Fax: 337-988-8751
Mailing address:
  • Phone: 337-981-6100
  • Fax: 337-988-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number107454R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: