Provider Demographics
NPI:1396742318
Name:THERIAULT, VICTOR GASTON (MD)
Entity type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:GASTON
Last Name:THERIAULT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:712 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-3004
Mailing Address - Country:US
Mailing Address - Phone:985-732-4853
Mailing Address - Fax:985-735-8883
Practice Address - Street 1:2905 E SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-2501
Practice Address - Country:US
Practice Address - Phone:334-420-5001
Practice Address - Fax:334-420-0160
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA014544207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1181251Medicaid
LAC72853Medicare UPIN
LA1181251Medicaid