Healthcare Provider Details

I. General information

NPI: 1417937517
Provider Name (Legal Business Name): VAUN J ARCHIBALD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 06/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1072 N LIBERTY ST SUITE 203
BOISE ID
83704-8708
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-4321
  • Fax: 208-367-4525
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberO-0449
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberO-0449
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: