Provider Demographics
NPI:1164500906
Name:VICTOR THERIAULT MD
Entity Type:Organization
Organization Name:VICTOR THERIAULT MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:THERIAULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-732-4853
Mailing Address - Street 1:712 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-3004
Mailing Address - Country:US
Mailing Address - Phone:985-732-4853
Mailing Address - Fax:
Practice Address - Street 1:712 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-3004
Practice Address - Country:US
Practice Address - Phone:985-732-4853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty