Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | DC10123 | CA |
NPI | 1114952629 |
---|---|
Provider Name | Dr. Peter Thibodeau |
First Address | Soquel, CA 95073-2920 |
Second Address | Soquel, CA 95073-2920 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T03826 | (02) | CA |