Basic Information
| Provider Information | |||||||||
| NPI: | 1083746507 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THIBODEAU | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12221 MERIT DR | ||||||||
| Address2: | SUITE 1610 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752512202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142171912 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12221 MERIT DR | ||||||||
| Address2: | SUITE 1610 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752512202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142171912 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2007 | ||||||||
| LastUpdateDate: | 05/27/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N2840 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 203457101 | 05 | TX | MEDICAID | 8CA552 | 01 | TX | BCBS | OTHER | P00814340 | 01 | TX | RAILROAD | OTHER |