Provider Demographics
NPI:1457670424
Name:ARCHER, KAETE ALEXANDRA (MD)
Entity Type:Individual
Prefix:
First Name:KAETE
Middle Name:ALEXANDRA
Last Name:ARCHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 W 16TH ST STE 3000
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2207
Practice Address - Country:US
Practice Address - Phone:317-944-6467
Practice Address - Fax:317-963-7085
Is Sole Proprietor?:No
Enumeration Date:2010-05-28
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35140196207Y00000X
IN01075043A207Y00000X, 207YX0905X
FLME128043207Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN063220091OtherMEDICARE PTAN