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General NPI Number Information
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NPI Number | 1033168042
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Entity Type | Individual
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Provider Name | MARIE-JOSEE THIBAULT M.D.
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Gender | Female
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Dates
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Enumeration Date | 05/08/2006
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Last Update Date | 11/06/2020
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Provider Practice Location Address
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Address Line | 5767 W CENTURY BLVD SUITE 200
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City | LOS ANGELES
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State | CA
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Zip | 90045-5632
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Country | US
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Telephone | 310-301-8708
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Fax | 310-301-8751
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Provider Business Mailing Address
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Address Line | 1615 HIGHWAY 34 E STE B
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City | NEWNAN
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State | GA
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Zip | 30265-1325
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Country | US
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Telephone | 310-301-8708
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Fax | 310-301-8751
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 84458
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | A51019
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | A51019
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License Number State | CA
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