Provider Demographics
NPI:1578750139
Name:THIBODEAUX, DAVID P (PT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:THIBODEAUX
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11418 LIVINGSTON RD
Mailing Address - Street 2:
Mailing Address - City:FT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-5145
Mailing Address - Country:US
Mailing Address - Phone:240-766-0300
Mailing Address - Fax:240-766-0304
Practice Address - Street 1:827 ROCKVILLE PIKE STE F
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-1267
Practice Address - Country:US
Practice Address - Phone:301-251-2777
Practice Address - Fax:240-766-0304
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD142104225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCS825OtherBLUE CROSS BLUE SHIELD
MDKB80OtherBLUE CROSS BLUE OF MD