MEDICARE: DR. ANDY ARCHULETA DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	E5929	CA

General Provider Information

NPI Number	:	1407417744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANDY ARCHULETA DPM

Provider Business Mailing Address
First Line	:	12303 DE PAUL DR
Second Line	:
City	:	BRIDGETON
State	:	MO
Zip	:	63044-2512
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 W LODI AVE STE W
Second Line	:
City	:	LODI
State	:	CA
Zip	:	95242-3037
Country	:	US
Telephone Number	:	209-334-6664
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2019
Last Update Date	:	07/27/2023

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Directions to “ DR. ANDY ARCHULETA DPM” Practice Location

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