Provider Demographics
NPI:1508877846
Name:ARCHER, ROGER W (DO)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:W
Last Name:ARCHER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3889
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-3889
Mailing Address - Country:US
Mailing Address - Phone:423-230-2100
Mailing Address - Fax:423-230-2112
Practice Address - Street 1:101 PROFESSIONAL PARK PVT DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-2288
Practice Address - Country:US
Practice Address - Phone:423-224-3350
Practice Address - Fax:423-239-8581
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1071207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5612721Medicaid
VA5612721Medicaid
TNE64396Medicare UPIN
TN080161859Medicare PIN