Provider Demographics
NPI:1871543090
Name:ARCHAMBAULT, JACQUES M (MD)
Entity type:Individual
Prefix:
First Name:JACQUES
Middle Name:M
Last Name:ARCHAMBAULT
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 1:260 CREST ROAD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ST ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478
Mailing Address - Country:US
Mailing Address - Phone:802-524-2663
Mailing Address - Fax:802-524-1953
Practice Address - Street 1:260 CREST ROAD
Practice Address - Street 2:SUITE 203
Practice Address - City:ST ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478
Practice Address - Country:US
Practice Address - Phone:802-524-2663
Practice Address - Fax:802-524-1953
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420007823207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN1987Medicaid
VT0VN1987Medicaid
VTVN1987Medicare ID - Type Unspecified