Provider Demographics
NPI:1609257914
Name:ARCHER, JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ARCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 W 16TH ST STE 5100
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-2274
Mailing Address - Country:US
Mailing Address - Phone:317-396-1300
Mailing Address - Fax:
Practice Address - Street 1:14101 PARKWAY COMMONS DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-6012
Practice Address - Country:US
Practice Address - Phone:405-749-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11018403A390200000X
OK38587207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program