Provider Demographics
NPI:1386705721
Name:THIBODEAUX, BRENT C (MD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:C
Last Name:THIBODEAUX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:11445 SUNSET HILLS RD
Practice Address - Street 2:KAISER PERMANENTE RESTON MEDICAL CENTER
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5276
Practice Address - Country:US
Practice Address - Phone:703-709-1500
Practice Address - Fax:703-709-1711
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD61216208000000X
DCMD034757208000000X
VA0101057696208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
006565M92Medicare ID - Type Unspecified
H32216Medicare UPIN