Healthcare Provider Details

I. General information

NPI: 1073551982
Provider Name (Legal Business Name): ROBERT THERIAULT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 BROAD ST STE 103
NASHUA NH
03063-3147
US

IV. Provider business mailing address

190 BROAD ST STE 103
NASHUA NH
03063-3147
US

V. Phone/Fax

Practice location:
  • Phone: 603-880-1511
  • Fax: 603-880-8511
Mailing address:
  • Phone: 603-880-1511
  • Fax: 603-880-8511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9290
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: