Provider Demographics
NPI:1174508105
Name:ARCHIBALD, OLIVER P (MD)
Entity Type:Individual
Prefix:DR
First Name:OLIVER
Middle Name:P
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 1:2807 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-4033
Mailing Address - Country:US
Mailing Address - Phone:865-207-8238
Mailing Address - Fax:
Practice Address - Street 1:2807 GRAND AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-4033
Practice Address - Country:US
Practice Address - Phone:865-207-8238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2023-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44390207P00000X
FLME75799207R00000X
NY289251208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255856400Medicaid
FL44725OtherBSFL
FL59068423OtherBSAL
FL7558225OtherAETNA
FL59068423OtherBSAL
FL44725WMedicare ID - Type Unspecified