Provider Demographics
NPI:1689291270
Name:THERIAULT, MARTIN DANIEL (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:DANIEL
Last Name:THERIAULT
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 1:3518 ROCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-2815
Mailing Address - Country:US
Mailing Address - Phone:207-239-9250
Mailing Address - Fax:
Practice Address - Street 1:3518 ROCHESTER RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-2815
Practice Address - Country:US
Practice Address - Phone:207-239-9250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301508399207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty