Provider Demographics
NPI:1699811406
Name:THIBODEAU, OMER (MD)
Entity Type:Individual
Prefix:DR
First Name:OMER
Middle Name:
Last Name:THIBODEAU
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 1:9 HEALTHCARE DR
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9449
Mailing Address - Country:US
Mailing Address - Phone:207-282-9080
Mailing Address - Fax:207-282-9080
Practice Address - Street 1:3 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9422
Practice Address - Country:US
Practice Address - Phone:207-284-4597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME7706174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME01 0398532OtherTRICARE
ME114440099Medicaid
MEB86995OtherHARVARD PILGRIM
ME01 0398532OtherCIGNA
NH30207619Medicaid
ME1041542OtherAETNA
ME114440000Medicaid
ME01 0398532OtherTRICARE
ME114440099Medicaid
ME13475901Medicare PIN