Provider Demographics
NPI:1659324515
Name:THIBAULT, MICHAEL STANLEY (PAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STANLEY
Last Name:THIBAULT
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 TAMARACK AVENUE
Mailing Address - Street 2:ADVANCED DERM CARE, PC
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06811
Mailing Address - Country:US
Mailing Address - Phone:203-797-8990
Mailing Address - Fax:203-748-7861
Practice Address - Street 1:25 TAMARACK AVENUE
Practice Address - Street 2:ADVANCED DERM CARE, PC
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06811
Practice Address - Country:US
Practice Address - Phone:203-797-8990
Practice Address - Fax:203-748-7861
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA 1933207Q00000X
CT001389207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPA1933OtherPA LICENSE
COPA1933OtherPA LICENSE