Provider Demographics
NPI:1619189396
Name:ARCHER, GARY (OMD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:ARCHER
Suffix:
Gender:M
Credentials:OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S FAIR OAKS AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2561
Mailing Address - Country:US
Mailing Address - Phone:626-795-7556
Mailing Address - Fax:
Practice Address - Street 1:301 S FAIR OAKS AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2561
Practice Address - Country:US
Practice Address - Phone:626-795-7556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC2987171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist