Provider Demographics
NPI:1861440463
Name:THEBAUT, ANTHONY LENNON (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:LENNON
Last Name:THEBAUT
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 1:12980 N SHORE DR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33410-1334
Mailing Address - Country:US
Mailing Address - Phone:561-622-6005
Mailing Address - Fax:
Practice Address - Street 1:7305 N MILITARY TRL
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33410-7417
Practice Address - Country:US
Practice Address - Phone:561-422-5781
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21023208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD55770Medicare UPIN
FL56083Medicare ID - Type Unspecified