Healthcare Provider Details

I. General information

NPI: 1871606442
Provider Name (Legal Business Name): JEAN-ETIENNE THIBAUD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1713-19 RALPH AVE
BROOKLYN NY
11236
US

IV. Provider business mailing address

PO BOX 100714 VANDERVEER STATION
BROOKLYN NY
11210-0714
US

V. Phone/Fax

Practice location:
  • Phone: 718-531-6100
  • Fax: 718-531-2329
Mailing address:
  • Phone: 718-531-6100
  • Fax: 718-531-2329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number224277
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: