Provider Demographics
NPI:1194874628
Name:THERIOT, MAXINE A (MD)
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:A
Last Name:THERIOT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MAXINE
Other - Middle Name:A
Other - Last Name:DAWES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:709 W RUSK ST STE B
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-3600
Mailing Address - Country:US
Mailing Address - Phone:972-786-0140
Mailing Address - Fax:972-786-0142
Practice Address - Street 1:3098 OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-8938
Practice Address - Country:US
Practice Address - Phone:573-686-8199
Practice Address - Fax:573-686-8398
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9578207Q00000X, 2083P0011X
MO20220472862083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81070JOtherBCBS
TXLOCATION 042OtherTRICARE SOUTH REGION
TX153020602Medicaid
TX038327501Medicaid
TXP00403008OtherRAILROAD MEDICARE
TX153020602Medicaid
TX8J3971Medicare PIN
TX81070JOtherBCBS