Provider Demographics
NPI:1093774192
Name:THIBODEAUX, KERRY THOMAS (MD FACS)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:THOMAS
Last Name:THIBODEAUX
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1270 ATTAKAPAS DR
Mailing Address - Street 2:STE 202
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-6549
Mailing Address - Country:US
Mailing Address - Phone:337-948-4362
Mailing Address - Fax:337-942-6523
Practice Address - Street 1:1270 ATTAKAPAS DR
Practice Address - Street 2:STE 202
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6549
Practice Address - Country:US
Practice Address - Phone:337-948-4362
Practice Address - Fax:337-942-6523
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA019158208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1374105Medicaid
LAB6490Medicare UPIN
LA53854Medicare ID - Type Unspecified