Provider Demographics
NPI:1275634107
Name:THIBODEAUX, JEFFREY J (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
Last Name:THIBODEAUX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 RUE LOUIS XIV
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5739
Mailing Address - Country:US
Mailing Address - Phone:337-769-7779
Mailing Address - Fax:337-769-7800
Practice Address - Street 1:200-A ENERGY PARKWAY
Practice Address - Street 2:SUITE 209
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508
Practice Address - Country:US
Practice Address - Phone:337-233-9546
Practice Address - Fax:337-237-5723
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021138208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1936120Medicaid
LA5R319Medicare ID - Type Unspecified
LA1936120Medicaid