Provider Demographics
NPI:1922487685
Name:THIBAULT, SOPHIE (MD)
Entity Type:Individual
Prefix:DR
First Name:SOPHIE
Middle Name:
Last Name:THIBAULT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 FOWLER GROVE BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-5597
Mailing Address - Country:US
Mailing Address - Phone:407-646-0042
Mailing Address - Fax:407-656-0633
Practice Address - Street 1:2200 FOWLER GROVE BLVD STE 220
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-5597
Practice Address - Country:US
Practice Address - Phone:407-646-0042
Practice Address - Fax:407-656-0633
Is Sole Proprietor?:No
Enumeration Date:2015-05-27
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME132235208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics