Individual
MARIE-JOSEE THIBAULT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
5767 W CENTURY BLVD, SUITE 200, LOS ANGELES, CA 90045-5632
(310) 301-8708
(310) 301-8751
Mailing address
1615 HIGHWAY 34 E, STE B, NEWNAN, GA 30265-1325
(310) 301-8708
(310) 301-8751
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
84458
GA
207N00000X
Dermatology Physician
Primary
A51019
CA
207ND0101X
MOHS-Micrographic Surgery Physician
A51019
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00A510190
—
CA
Enumeration date
05/08/2006
Last updated
11/06/2020
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