Provider Demographics
NPI:1073958658
Name:THIBODEAUX, SUZANNE RENEE (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:RENEE
Last Name:THIBODEAUX
Suffix:
Gender:F
Credentials:MD PHD
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Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-5641
Mailing Address - Fax:314-362-0369
Practice Address - Street 1:425 S EUCLID AVE
Practice Address - Street 2:DIV PA LAB AND GENOMIC MED
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1005
Practice Address - Country:US
Practice Address - Phone:314-362-5641
Practice Address - Fax:314-362-0369
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2017030247207ZC0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200046010Medicaid