Provider Demographics
NPI:1538342431
Name:THIBODEAUX, AMBROSE CARROLL JR (MT)
Entity type:Individual
Prefix:MR
First Name:AMBROSE
Middle Name:CARROLL
Last Name:THIBODEAUX
Suffix:JR
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 CHOCTAW DR
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-6567
Mailing Address - Country:US
Mailing Address - Phone:337-934-6453
Mailing Address - Fax:
Practice Address - Street 1:1015 CHOCTAW DR
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6567
Practice Address - Country:US
Practice Address - Phone:337-934-6453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACLP.G02111-GEN246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1499OtherBRD CLIN LAB SCIEN PRACT
NE19554TCL-0OtherBUR OF LIC & CERT.
LACLP.G02111-GENOtherST BRD MEDICAL EXAMINES