Provider Demographics
NPI:1609980713
Name:THERIAULT, ALEXANDRA (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:THERIAULT
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 1:1420 W CANAL CT
Mailing Address - Street 2:#50
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120-5655
Mailing Address - Country:US
Mailing Address - Phone:303-795-2030
Mailing Address - Fax:303-795-2153
Practice Address - Street 1:1420 W CANAL CT
Practice Address - Street 2:#50
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80120-5655
Practice Address - Country:US
Practice Address - Phone:303-795-2030
Practice Address - Fax:303-795-2153
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38122207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO59251573Medicaid
CO59251573Medicaid
COH22977Medicare UPIN