Provider Demographics
NPI:1700832086
Name:THIBAULT, AMY (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:THIBAULT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 TILLEY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-4484
Mailing Address - Country:US
Mailing Address - Phone:802-862-7338
Mailing Address - Fax:802-862-8411
Practice Address - Street 1:185 TILLEY DR
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-4484
Practice Address - Country:US
Practice Address - Phone:802-862-7338
Practice Address - Fax:802-862-8411
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2010-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420010606207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009872Medicaid
VT1009872Medicaid
VTH95797Medicare UPIN