Provider Demographics
NPI:1083781611
Name:ARCHIBALD, MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:ARCHIBALD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FOXCARE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ONEONTA
Mailing Address - State:NY
Mailing Address - Zip Code:13820-2086
Mailing Address - Country:US
Mailing Address - Phone:607-432-1262
Mailing Address - Fax:607-432-3011
Practice Address - Street 1:1 FOXCARE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-2086
Practice Address - Country:US
Practice Address - Phone:607-432-1262
Practice Address - Fax:607-432-3011
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003328152W00000X
NYTUV003328152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC27451Medicare UPIN
NYT81458Medicare ID - Type Unspecified