Provider Demographics
NPI:1104041326
Name:ARCHIBALD, DAVID JONAS (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JONAS
Last Name:ARCHIBALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2352 MEADOWS BLVD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80109-8406
Mailing Address - Country:US
Mailing Address - Phone:303-268-2222
Mailing Address - Fax:
Practice Address - Street 1:2352 MEADOWS BLVD
Practice Address - Street 2:SUITE 290
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80109-8406
Practice Address - Country:US
Practice Address - Phone:303-268-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-14
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49658207Y00000X
FLME103522207Y00000X
WAMD60286714207Y00000X, 207YS0123X
CODR.0053492207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN205455000Medicaid
FL14F11OtherBLUE CROSS BLUE SHIELD
FL003610900Medicaid
CO32778856Medicaid
FL14F11OtherBLUE CROSS BLUE SHIELD
FL003610900Medicaid