Provider Demographics
NPI:1083746507
Name:THIBODEAU, BRYAN C (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:C
Last Name:THIBODEAU
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 1:12221 MERIT DR
Mailing Address - Street 2:SUITE 1610
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251-2202
Mailing Address - Country:US
Mailing Address - Phone:214-217-1912
Mailing Address - Fax:
Practice Address - Street 1:12221 MERIT DR
Practice Address - Street 2:SUITE 1610
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-2202
Practice Address - Country:US
Practice Address - Phone:214-217-1912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2840207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX203457101Medicaid
TX8CA552OtherBCBS
TXP00814340OtherRAILROAD
TX203457101Medicaid