=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962516039
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DWIGHT THIBODEAUX O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2006
-----------------------------------------------------
Last Update Date | 02/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1409 LUISA ST SUITE D
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-7002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-984-8989
-----------------------------------------------------
Fax | 505-984-8892
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1409 LUISA ST SUITE D
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-7002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-984-8989
-----------------------------------------------------
Fax | 505-984-8892
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 300
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------