Provider Demographics
NPI:1417937517
Name:ARCHIBALD, VAUN J (DO)
Entity Type:Individual
Prefix:
First Name:VAUN
Middle Name:J
Last Name:ARCHIBALD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1072 N LIBERTY ST
Practice Address - Street 2:SUITE 203
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8708
Practice Address - Country:US
Practice Address - Phone:208-367-4321
Practice Address - Fax:208-367-4525
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-04492080A0000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807789500Medicaid