Provider Demographics
NPI:1871606442
Name:THIBAUD, JEAN-ETIENNE (MD)
Entity type:Individual
Prefix:DR
First Name:JEAN-ETIENNE
Middle Name:
Last Name:THIBAUD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100714
Mailing Address - Street 2:VANDERVEER STATION
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-0714
Mailing Address - Country:US
Mailing Address - Phone:718-531-6100
Mailing Address - Fax:718-531-2329
Practice Address - Street 1:1713-19 RALPH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236
Practice Address - Country:US
Practice Address - Phone:718-531-6100
Practice Address - Fax:718-531-2329
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224277207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
NY02366750Medicaid
NY0247P1Medicare PIN
NY331954Medicare PIN