Healthcare Provider Details

I. General information

NPI: 1144459793
Provider Name (Legal Business Name): DAVID MICHAEL ARCHIBALD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2009
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W MAIN ST STE A
JOHN DAY OR
97845-1075
US

IV. Provider business mailing address

401 W MAIN ST STE A
JOHN DAY OR
97845-1075
US

V. Phone/Fax

Practice location:
  • Phone: 541-575-1819
  • Fax: 541-575-0965
Mailing address:
  • Phone: 541-575-1819
  • Fax: 541-575-0965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3534AT
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500671241
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: