Provider Demographics
NPI:1730190109
Name:THIBODEAU, DANIEL JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JOHN
Last Name:THIBODEAU
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 E NORTHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8415
Mailing Address - Country:US
Mailing Address - Phone:920-954-1002
Mailing Address - Fax:920-954-1006
Practice Address - Street 1:1221 E NORTHLAND AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8415
Practice Address - Country:US
Practice Address - Phone:920-954-1002
Practice Address - Fax:920-954-1006
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2614111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38848700Medicaid
WI35228Medicare ID - Type Unspecified
WIU01306Medicare UPIN