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General NPI Number Information
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NPI Number | 1396742318
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Entity Type | Individual
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Provider Name | VICTOR GASTON THERIAULT MD
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Gender | Male
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Dates
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Enumeration Date | 07/05/2005
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Last Update Date | 03/26/2025
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Provider Practice Location Address
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Address Line | 2905 E SOUTH BLVD
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City | MONTGOMERY
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State | AL
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Zip | 36116-2501
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Country | US
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Telephone | 334-420-5001
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Fax | 334-420-0160
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Provider Business Mailing Address
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Address Line | 712 WILLIS AVE
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City | BOGALUSA
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State | LA
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Zip | 70427-3004
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Country | US
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Telephone | 985-732-4853
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Fax | 985-735-8883
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 014544
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License Number State | LA
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