Provider Demographics
NPI:1588660161
Name:ARCHDALE, THEODORE WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:WILLIAM
Last Name:ARCHDALE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:TED
Other - Middle Name:WILLIAM
Other - Last Name:ARCHDALE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1541 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-1923
Mailing Address - Country:US
Mailing Address - Phone:719-577-4400
Mailing Address - Fax:719-577-4954
Practice Address - Street 1:1541 S 8TH ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-1923
Practice Address - Country:US
Practice Address - Phone:719-577-4400
Practice Address - Fax:719-577-4954
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1466152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO26777312Medicaid
CO08014664Medicaid
CO99752212Medicaid
CO4708600001Medicare NSC
COU00898Medicare UPIN
COC461238Medicare PIN
CO99752212Medicaid
COC461258Medicare PIN