Provider Demographics
NPI:1568565034
Name:ARCHER, JOHN T (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:ARCHER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 ERIE COURT
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402
Mailing Address - Country:US
Mailing Address - Phone:419-352-2505
Mailing Address - Fax:419-352-1281
Practice Address - Street 1:1222 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2664
Practice Address - Country:US
Practice Address - Phone:419-352-2505
Practice Address - Fax:419-352-1281
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3159 T890152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0283063Medicaid
OHT46841Medicare UPIN
OH0431685Medicare PIN
OH0283063Medicaid
OH0431684Medicare PIN