Provider Demographics
NPI:1134200033
Name:THEROUX, DEANA MARIE (MD)
Entity type:Individual
Prefix:
First Name:DEANA
Middle Name:MARIE
Last Name:THEROUX
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 1:795 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02721-1733
Mailing Address - Country:US
Mailing Address - Phone:508-235-5285
Mailing Address - Fax:508-678-6905
Practice Address - Street 1:795 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-1733
Practice Address - Country:US
Practice Address - Phone:508-235-5285
Practice Address - Fax:508-678-6905
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2003-00716208000000X
MA2350542080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891347GMedicaid
NCH02939Medicare UPIN