Basic Information
| Provider Information | |||||||||
| NPI: | 1033168042 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THIBAULT | ||||||||
| FirstName: | MARIE-JOSEE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1615 HIGHWAY 34 E | ||||||||
| Address2: | STE B | ||||||||
| City: | NEWNAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302651325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103018708 | ||||||||
| FaxNumber: | 3103018751 | ||||||||
| Practice Location | |||||||||
| Address1: | 5767 W CENTURY BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103018708 | ||||||||
| FaxNumber: | 3103018751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 84458 | GA | N | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | A51019 | CA | N | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207N00000X | A51019 | CA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 00A510190 | 05 | CA | MEDICAID |