1396742318 NPI number — DR. VICTOR GASTON THERIAULT MD

Table of content: DR. VICTOR GASTON THERIAULT MD (NPI 1396742318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396742318 NPI number — DR. VICTOR GASTON THERIAULT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THERIAULT
Provider First Name:
VICTOR
Provider Middle Name:
GASTON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1396742318
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
712 WILLIS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOGALUSA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70427-3004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-732-4853
Provider Business Mailing Address Fax Number:
985-735-8883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2905 E SOUTH BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTGOMERY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36116-2501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-420-5001
Provider Business Practice Location Address Fax Number:
334-420-0160
Provider Enumeration Date:
07/05/2005

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: 207Q00000X , with the licence number:  014544 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1181251 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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