Provider Demographics
NPI:1114952629
Name:THIBODEAU, PETER (DC)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:THIBODEAU
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3121 PARK AVE
Mailing Address - Street 2:B
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073-2920
Mailing Address - Country:US
Mailing Address - Phone:831-462-2727
Mailing Address - Fax:
Practice Address - Street 1:3121 PARK AVE
Practice Address - Street 2:B
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-2920
Practice Address - Country:US
Practice Address - Phone:831-462-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC10123111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT03826Medicare UPIN