Provider Demographics
NPI:1144243007
Name:THIBODEAUX, JOHN SULIE (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:SULIE
Last Name:THIBODEAUX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 E EDWARD ST
Mailing Address - Street 2:
Mailing Address - City:ERATH
Mailing Address - State:LA
Mailing Address - Zip Code:70533-4114
Mailing Address - Country:US
Mailing Address - Phone:337-470-3250
Mailing Address - Fax:337-937-5806
Practice Address - Street 1:402 E EDWARD ST
Practice Address - Street 2:
Practice Address - City:ERATH
Practice Address - State:LA
Practice Address - Zip Code:70533-4114
Practice Address - Country:US
Practice Address - Phone:337-470-3250
Practice Address - Fax:337-937-5806
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13009207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1148164Medicaid
B89826Medicare UPIN
LA55305Medicare PIN