Provider Demographics
NPI:1528078896
Name:THERIAULT, JOSEPH G (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:G
Last Name:THERIAULT
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 1:30 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VT
Mailing Address - Zip Code:05477-4479
Mailing Address - Country:US
Mailing Address - Phone:802-434-4123
Mailing Address - Fax:802-434-3130
Practice Address - Street 1:30 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VT
Practice Address - Zip Code:05477-4479
Practice Address - Country:US
Practice Address - Phone:802-434-4123
Practice Address - Fax:802-434-3130
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420010278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1008108Medicaid
VN2664Medicare ID - Type Unspecified
VT1008108Medicaid