Provider Demographics
NPI:1780822478
Name:THERIAULT, RACHEL LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:LEIGH
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-0813
Practice Address - Street 1:500 S HENDERSON ST STE 200
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2154
Practice Address - Country:US
Practice Address - Phone:817-413-1500
Practice Address - Fax:817-413-1499
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXM7685207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200172903Medicaid