Provider Demographics
NPI:1245572031
Name:THIBODEAUX, VANESSA CLOUTIER (MD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:CLOUTIER
Last Name:THIBODEAUX
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 1:320 RACETRACK RD NW STE 100A
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1796
Mailing Address - Country:US
Mailing Address - Phone:850-315-8360
Mailing Address - Fax:
Practice Address - Street 1:320 RACETRACK RD NW STE 100A
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1796
Practice Address - Country:US
Practice Address - Phone:850-315-8360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-20
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.305061207VX0000X
390200000X
FLME147842207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program