Provider Demographics
NPI:1972698918
Name:THIBODEAUX, JOEL D (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:D
Last Name:THIBODEAUX
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:PO BOX 3780
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3780
Mailing Address - Country:US
Mailing Address - Phone:318-841-9526
Mailing Address - Fax:
Practice Address - Street 1:1701 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8911
Practice Address - Country:US
Practice Address - Phone:337-494-3190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3344207ZP0102X
LA025001207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1423602Medicaid
1972698918OtherINDIVIDUAL NPI NUMBER