1053440933 NPI number — DONNA M THIBODEAU MD

Table of content: DONNA M THIBODEAU MD (NPI 1053440933)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053440933 NPI number — DONNA M THIBODEAU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THIBODEAU
Provider First Name:
DONNA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053440933
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 26666
Provider Second Line Business Mailing Address:
PHS PROVIDER ENROLLMENT
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87125-6666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-923-5356
Provider Business Mailing Address Fax Number:
505-923-5354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 N DR MARTIN LUTHER KING JR BLVD
Provider Second Line Business Practice Location Address:
CLOVIS PLAINS REG MED CTR
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88101-9412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-769-2141
Provider Business Practice Location Address Fax Number:
505-769-7337
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  86135 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 37507 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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