Provider Demographics
NPI:1093763625
Name:THERIOT, JEANNE DAUPHINE (MD)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:DAUPHINE
Last Name:THERIOT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 CHAMPAGNE BLVD
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-3852
Mailing Address - Country:US
Mailing Address - Phone:337-332-2242
Mailing Address - Fax:337-332-4074
Practice Address - Street 1:112 CHAMPAGNE BLVD
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-3852
Practice Address - Country:US
Practice Address - Phone:337-332-2242
Practice Address - Fax:337-332-4074
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200073207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1062472Medicaid
LA4K145Medicare PIN
LAP00323115Medicare PIN