Provider Demographics
NPI:1962516039
Name:THIBODEAUX, DWIGHT (OD)
Entity type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:
Last Name:THIBODEAUX
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 LUISA ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7002
Mailing Address - Country:US
Mailing Address - Phone:505-984-8989
Mailing Address - Fax:505-984-8892
Practice Address - Street 1:1409 LUISA ST
Practice Address - Street 2:SUITE D
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7002
Practice Address - Country:US
Practice Address - Phone:505-984-8989
Practice Address - Fax:505-984-8892
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM201009924OtherPRESBYTERIAN HEALTH PLAN
NM850448729TOtherBLUE CROSS BLUE SHIELD #
NM850448729OtherLOVELACE HEALTH PLAN
NMUNITED HEALTH CAREOther850448729
NM201009924OtherPRESBYTERIAN HEALTH PLAN