Provider Demographics
NPI:1689616260
Name:THIBAULT, KATHLEEN S (DO)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:S
Last Name:THIBAULT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MILO
Mailing Address - State:ME
Mailing Address - Zip Code:04463-1729
Mailing Address - Country:US
Mailing Address - Phone:207-943-7752
Mailing Address - Fax:207-943-1002
Practice Address - Street 1:135 PARK ST
Practice Address - Street 2:
Practice Address - City:MILO
Practice Address - State:ME
Practice Address - Zip Code:04463-1729
Practice Address - Country:US
Practice Address - Phone:207-943-7752
Practice Address - Fax:207-943-1002
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1613207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G93131Medicare UPIN
MEMM7789Medicare ID - Type Unspecified