Provider Demographics
NPI:1427093293
Name:MJ THIBAULT, MD, INC
Entity type:Organization
Organization Name:MJ THIBAULT, MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIE-JOSEE
Authorized Official - Middle Name:
Authorized Official - Last Name:THIBAULT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-632-0070
Mailing Address - Street 1:227 N EL CAMINO REAL
Mailing Address - Street 2:STE 100
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-5821
Mailing Address - Country:US
Mailing Address - Phone:760-632-0070
Mailing Address - Fax:760-632-0071
Practice Address - Street 1:227 N EL CAMINO REAL
Practice Address - Street 2:STE 100
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5821
Practice Address - Country:US
Practice Address - Phone:760-632-0070
Practice Address - Fax:760-632-0071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51019174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF54111Medicare UPIN