Provider Demographics
NPI:1194823336
Name:THERIOT, PAMELA ELAINE (OD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:ELAINE
Last Name:THERIOT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:PAMELA
Other - Middle Name:ELAINE
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:451 ASHLEY RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7229
Mailing Address - Country:US
Mailing Address - Phone:318-222-5555
Mailing Address - Fax:318-222-6414
Practice Address - Street 1:451 ASHLEY RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-7229
Practice Address - Country:US
Practice Address - Phone:318-222-5555
Practice Address - Fax:318-222-6414
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12195T152W00000X
LA1805-739152W00000X
NM551152W00000X
AZ1592152W00000X
TX6697T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U87500Medicare UPIN
AZ118868Medicare PIN