Provider Demographics
NPI:1376529768
Name:ARCHAMBEAU, LURLEY JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:LURLEY
Middle Name:JOHN
Last Name:ARCHAMBEAU
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 1:6450 WEATHERFIELD CT
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-9146
Mailing Address - Country:US
Mailing Address - Phone:419-866-2830
Mailing Address - Fax:419-866-2831
Practice Address - Street 1:6450 WEATHERFIELD CT
Practice Address - Street 2:SUITE 1B
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-9146
Practice Address - Country:US
Practice Address - Phone:419-866-2830
Practice Address - Fax:419-866-2831
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35999174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0275330Medicaid
OHAR0412653Medicare PIN
OH0275330Medicaid