Provider Demographics
NPI:1902992308
Name:THIBODEAU, PATRICE M (MD)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:M
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28000 MEADOW DR UNIT 210
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-2116
Mailing Address - Country:US
Mailing Address - Phone:303-679-8500
Mailing Address - Fax:303-679-8505
Practice Address - Street 1:28000 MEADOW DRIVE #210
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439
Practice Address - Country:US
Practice Address - Phone:303-679-8500
Practice Address - Fax:303-679-8505
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0054626207R00000X, 2080A0000X
MEMD15542208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC544638OtherEMPLOYER PTAN
CO378538YY4GOtherPTAN
COC544638OtherEMPLOYER PTAN
MEG19861Medicare UPIN
CO378538YY4GOtherPTAN