Provider Demographics
NPI:1033168042
Name:THIBAULT, MARIE-JOSEE (MD)
Entity Type:Individual
Prefix:
First Name:MARIE-JOSEE
Middle Name:
Last Name:THIBAULT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1615 HIGHWAY 34 E
Mailing Address - Street 2:STE B
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-1325
Mailing Address - Country:US
Mailing Address - Phone:310-301-8708
Mailing Address - Fax:310-301-8751
Practice Address - Street 1:5767 W CENTURY BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-5632
Practice Address - Country:US
Practice Address - Phone:310-301-8708
Practice Address - Fax:310-301-8751
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA84458207N00000X
CAA51019207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A510190Medicaid
CAF54111Medicare UPIN