Basic Information
| Provider Information | |||||||||
| NPI: | 1386705721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THIBODEAUX | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 E JEFFERSON ST | ||||||||
| Address2: | KAISER PERMANENTE MEDICARE ENROLLMENT | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018162424 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11445 SUNSET HILLS RD | ||||||||
| Address2: | KAISER PERMANENTE RESTON MEDICAL CENTER | ||||||||
| City: | RESTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201905276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037091500 | ||||||||
| FaxNumber: | 7037091711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | D61216 | MD | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD034757 | DC | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 0101057696 | VA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.